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HomeMy WebLinkAbout0045 EBEN SMITH ROAD - Health 45 Eben Smith Road A= 171 —200 Centerviiie i 1/U ��+raro t Slla� �� i UPC 12543 a No. R ' HASTINGS, MM f gay 16 14 03:02p p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 5-15-14 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filinoln the computer, ���`���H OFff out forms h24Ss use only the tab 1. Inspector: I �5 ;`�_�= •qby key to move your gam:' JA M E S • G cursor do not James D.Sears 21; use the return — — Inspector of Inspeor key. CapewideEnterprises,LLCCompany Name ' o r 153 Commercial Street 5 INS? �``°` >>rrpff;t;t;;;��t' Company Address Mashpee MA 02649 CityrTown - State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-15-14 . pector'sSignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority.(Board of Health or DEP).within 30 days of completing this inspection. IF the system is a shared system or has a design flow of 10,000.gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "*"*This report only describes;conditions at the time of inspection and under the conditions of use at that time.This Inspection does not address how the system will perform in the future under the same or different conditions of use. _ t5ins•3113 TM 5 Official lnspe .. orm SUmifaoe Sewage Dispose)System•Page 1 of 17 May 16 14 03:02p p.2 Commonwealth of Massachusetts Title 5 Officials Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 5-15-14 page_ CityfTown State Zip Code. Date of Inspection B. Certification (cont.) Inspection Summary: Check' A,B,C,D or E/always complete all of Section D A) System Passes: t ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: 13) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will:pass. Check the box for"yes", "no°or"not determined"(Y, N, ND)for the following statements. If"not determined," please explaini The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15irts•W13 t Tift 5 Otfidel hspedmn Form:Subs irface Sewage Disposal System-Page 2 of 17 May 16 14 03:02p p.3 Commonwealth of Massachusetts Title 5 Official', Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar Owner owner's Name information is Centerville MA 02632 5-15-14 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): z s ❑ obstruction is removed ❑ Y ❑ N ❑' ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)arq replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: '❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 9 15ins•3113 TNe 5 Official Inspection Fonn:Subsurface Sewage Disposal Syslam•Page 3 of 17 May 16 14 03:03p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal-.System Form-Not for Voluntary Assessments 45 Eben Smith Road _ Property Address Richard Lamar Owner Owner's Name _ information is required for every Centerville MA 02632 5-15-14 page, Citylrown State Zip Code Date of Inspedion B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is.functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ .The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well•". Method used to determine distance: "*This system passes if the;well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: , ♦ 9 I 1. i' D) System Failure Criteria Applicable to All Systems: You. must Indicate"Yes"or,!`No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Uquid'de,pth in egafflMO.is less than 6' below invert or available volume is less than day flow P1 T' 15ins•'3M 3 .= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 or 17 i May 16 14 03:03p p.5 Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 5-15-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. fi. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other'failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,0009pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd;to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No = ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ Elthe system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-a IWPA)or a mapped Zone It of a public water supply well If you have answered"yes"to'any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or•failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 5ns•?J13 Tille 5 Olridal espedion Farm:Subsurface Sewage Disposal System•Page 5 of IT (i May 16 14 03:03p p.6 Commonwealth of Massachusetts _ Title 5 Official'i Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 5-15-14 page. CityfTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any'of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were at built plans of the system obtained and examined?(If they were not AAA ❑ . ❑ availabfe note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: { ❑ ® Existing information. For example, a plan at the Board of Health. F, ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Informatidn 4 Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsrface Sewage Disposal System•Page 6 of 1T y May 16 14 03:04p p.7 r Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 3 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville t MA 02632 5-15.-14 page- Cityf rown d State Zip Code Date of Inspection D. System Information' Description: The system is a.1000 Gal. Tank, D Box and pit. Number of current residents: 0 t . Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected?' ❑ Yes ® No Seasonal use? ❑ Yes ® No 2012-25,000Gals Water meter readings, if available(last 2 years usage (gpd)): 2013-18,00OGaI's Detail: t F Sump pump? ❑ Yes ® No NA Last date of occupancy: Date Commercial/Industrial Flow,Conditions: i Type of Establishment: ----------- — Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ire•3113 Title 5 Official Inspection Form:Stbsurfaice Seviage Dispcsal System-Page 7 of 17 i May 16 14 03:04p p.8 Commonwealth of Massachusetts UWTTitle 5 Official` Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Eben Smith Road } Property Address Richard Lamar Owner Owner's Name information is required for every Centerville = MA 02632 5-15-14 page. City/Town state Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/user Date Other(describe below): General Information C •.T Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No I If yes, volume pumped:. gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,. distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ InnovativelAltemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t t5ins 3113 Tile S Official Inspection Form:Subsurfstm Sewage Disposal System-Page 8 of 17 f May 16 14 03:04p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal Aystem Form-Not for Voluntary Assessments 45 Eben Smith Road `- Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 5-15-14 page. Citylrown State Zip Code Date of inspection D. System Inform atiop,,(cont.) Approximate age of all components, date installed (if known)and source of information: Around 19801 New D Box and line 5-14. a Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate om.site plan): Depth below grade: x 17 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water,supply well or suction line: feet Comments(on condition ofjoints, venting,evidence of leakage, etc.): Pipeing is4" PVC SCH 40.1111 . I i. Septic Tank (locate on site.`plan): Depth below grade: feet a i Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 Gal. Precast Dimensions: 211 Sludge depth: t5ins-3/13 Tllte 5 Official Inspection Form:Subsurfaos Serage Disposal System-Page 9 of 17 May 16 14 03:05p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form i 1N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is Centerville MA 02632 5-15-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" -- 11 Scum thickness 0 Distance from top of scum to top of out tee or baffle 12" 1811 Distance from bottom of scum to bottom of outlet tee or baffle b Tape-Sludge-Judge How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level. Tank and covers at 7" below grade. In tee, outlet tee. No sign of leakage or over loading Grease Trap(locate on site plan): 'I Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to,top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle -- — Date of last pumping: Date t5ins-3113 TNe 5 Ofdai Inspection Form:Subsurface Sewage Disposal System-Page 10 o1 17 May 16 14 03:05p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar _ Owner Owners Name information is required for every Centerville _ MA 02632 5-15-14 page.- Cityrrown State Zip Code Date of Inspection D. System Information '(cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t 9 Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal, ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: a. - Capacity: gallons Design Flow: ---- gallons per day Alarm present: ❑ Yes ❑ No j Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches,etc.): is r *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Mns-3113 TLe 59f iicial Inspecticn Form:Subsurface Sewage Disposal System•Page 11 of 17 May 16 14 03:05p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar Crooner Owner's Name information is Centerville AAA 02632 5-15-14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cost.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-16"below grade wlcover at 6". One line out, D Box is new 5-14.. Pump Chamber(locate on site plan): Pumps in working order ❑ Yes ❑ No` Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): r . If pumps or alarms are not';in working order, system is a conditionai pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5in9•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System,Page 12 of 17 May 1614 03:06p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 5-15-14 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number_ 1 ❑ leaching chambers number: — ❑ leaching galleries number: a ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast pit w/2'stone. Pit and cover at 22" below grade. 6"water in pit w/stain line and wet wall's at 3'. No sign of over loading. s I Cesspools (cesspool must bepumped as part of inspection)(locate on site plan): Number and configuration S Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 'sins•3n3 Title 5 Official Inspectlon Fow Subsurface Sewage Disposal System•Page 13 of 17 May 16 14 03:06p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Eben Smith Road I Property Address Richard Lamar Owner Owner's Name information Is required for every Centerville i MA 02632 5-15-14. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ,i Privy(locate on site plan): Materials of construction: Dimensions t Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f f � I 'n l5ins 3113 Title 5 Official Inspection Fomr.Subswfece Sewage Dipmel System-Page 14 of 17 May 16 14 03:06p p.15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 5-15-14 page. Cityrrown State Zip Code Date of Inspection D. System Information :(cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check-one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately R E/m g Y;2 30 o4- ° ❑ 3 { ISIns•3113 Trt!e 5 Offida:Inspection form Subsirface Sewage D"icposal System-Page 15 of 17 May 16 14 03:07p p.16 Commonwealth of Massachusetts ltTTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 _ 5-15-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ` ❑ Surface water ❑ Check cellar I ❑ Shallow wells o n f 12}, Estimated depth torhigh ground water feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date a of design plan reviewed: pate ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: i i You must describe how you:established the high ground water elevation: Hand Auger 12'no G.W Bottom of pit at 8' below grade. Bottom of pit at 4' above Auger Hole 1. Before filing this Inspection Report,please see Report Completeness Checklist on next page. i5ins•3M3 Td e 5 Ofrrda Inspection Form:Subsurlace Sewage Disposal Syslem•Page 16 cf 17 May 16 14 03:07p p.17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Eben Smith Road Property Address Richard Lamar Owner Owner's Name information is required for every Centerville MA 02632 5-15-14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information- Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file h1 i i 1 - t5ns•3113 Title 5 Offidel Inspection Fonn:Subsurface Sewage Disposal System•Page 17 of 17 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS gppfitation for Misposaf *pstem Construction 3permit Application for a Permit to Construct( ) Repair o� Upgrade( ) Abandon( ) ❑Complete System [Andividual Components Location Address or Lot No. 145 EOC-4 SM t tH PLO Owner's Name,Address and Tel.No. �.l fdt e.Lc 'Rtcc"� ft LAMA!;i, Assessor's Map/Parcel 1171 gyp© a30 I S ita oSS S` NF— c a+ 5,f0 VK Sip Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. CAPEW04E�Ej1?t99_1A_6<$ "X_ ' Gc�kr wceL�A+✓ �� ®►-t�4StfPc'� NlA l Type of Building: Dwelling No.of Bedrooms Lot Size C 5j 44kO t sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) D"Ac* ALM FROA,,� 12gd)L2n P t i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health- Sk6ed Date S "o—.;L Application Approved by Date S Application Disapproved by Date for the following reasons Permit No. C-go/ y _ �� Date Issued 3 ` No-` / /✓ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in omputer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliLatlon for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System `` Individual Components {5 Eor_q SNt Location Address or Lot No. t t 4 N (Zo Owner's Name,Address,and Tel.No.% _1/VIL-f 6 Rtc-&44-RD L-AmA4, Assessor's Map/Parcel a pp a301 S kq o5S STZNE Ge• 55/Old F�u-S Installer's Name,�Address,and Tel.No. Designer's Name,Address,and Tel.No. A IDE �R AQtSES LL4-- NA - Type of Building: - L � T Dwelling No.of Bedrooms Lot Size 15,)41 2 sq.ft. Garbage Grinder( ) P Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) �—DDD�C&c,� ��Li�'f Lt�� F,��.t �'�'rC'' •�)'4'ly�) i' Date last inspected: Agreement: 8. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of M. Compliance has been issued by this-Board of Health. Signed Date S 13 'o1Q[ Application Approved by Date Application Disapproved by Date a for the following reasons Permit No. �,C / L1 — �,j 4— Date Issued J 3 THE COMMONWEALTH OF MASSACHUSETTS (� BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( x) Upgraded( ) Abandoned( )by C A P�(.)I Txs- Ekj7euQQI Sze, (LC_ at C4C S 714 �n��j U/�[ � has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No� `[1 � dated C!�4 'i Installer V c�(1�� t--I�T �/�1�5 CLC. Designer #bedrooms Approved design flow gpd The issuance of this permit shall /not be}construed as a guarantee that the system will funct o as designed. Date r/ �l/I Z 1 Inspector No. �:)L%)L -- _5 Lj Fee /0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal bpBtem Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at � �� SWIM4 11/c.4 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be,completejf within three years of the date of this pe ir(n t. Date / / J Approved by No...... Y3L- Fss............................. THE COMMONWEALTH OF MASSACHUSETTS `P BOARD­0f HEALTH oa ........oF.......... . ----------------•-----•---------.-.-------------•-- Aliptiration for Disposal Works Tonstru.r#iun lirrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System . 16.. ........ ... -------------------------------- •-- Lo tion-Addres Lot•-io — ••. - ----••- -•------------------- ......_......... es Owner s w ... Installer Address LL Type of uilding Size Lot... _.V-- -Sq. feet U Dwelling—No. of Bedrooms..__...............................Expansion Attic Garbage Grinder '4 Other—T e of Building No. of persons............................ Showers — Cafeteria a O e fixtures �-7 •------------------------------•-----------•-----------...•....-----•--•------------------------ w Design Flow....... .___. ..................gallons per person per day. Total daily flow.___....�.3..(:5...............gallons. WSeptic Tank—Liquid capacity .gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ..........Z....... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----(4.0--P.. Diameter....(......... Depth below inlet.................... Total leaching area.._......._.......sq. ft. Z Other Distributionox ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1,...............minutes per inch Depth of Test Pit.................... Depth to ground water-____-____-________--_-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p+' ................... )- ----------.....-•-••..._..... . --------- Description of Soil........... h.4S x •-•-•-•-••••- �., w ••-•--•-••-•----------------•-----••---••••-•--•------••-•-••-•--------•-•--•-----•--•-•---•-•--•---•-•-••-----••••---•--...-•-•----••---------••------••-•....•••-••-------------------••--•-•--•-•-•-- UNature of Repairs or Alterations—Answer when applicable............................................................................................... .............................................................. ..•••••••-•............. •--------------------- ---------------------------------------------- ._._.....---------- Agreement: The undersigned agrees to install the aforedescribed Individual Sew e Disposal System in accordance with the provisions of iI?i L 5 of the State Sanitary Code—The undersigne rtl:er agrees not to plac the system in operation until a Certificate of Compliance has been 'Vi by the rd o iealth. / Si -•---•-•••...-••-- ....................................... 1-• .... Date Application Approved By.. - - =:.. . .. ...1u�1 -�...................tiJ�� � ate Application Disapproved for the following reasons:-----•----------------•---------------------•------------- ..................................................... ---•--•---•.....................................•--------•---------------...---------........-------•----------.........----------------------------y------ -------------------------------------- • Date PermitNo......................................................... Issued------- ................�- ----•--_ ......--... Date $ No........ 13 kc` Fs$............................. HE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH Appliration fnr Dispersal Works Tonstrnrtiun ramit Application is hereby made jor.a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ..........:... ......... ... Location Address r or Lot»No+'� -------- -- ---•• ----------------------Owner Address -- W - .. - - _ Installer Address Type of wilding Size Lot___ �_-=_._,:,:6:1V Sq. fe t a Dwellg—No. of Bedrooms----- __________Expansion Attic V)-0 Garbage Grinder ( 6 a Other-Type of Building _________________________ No of persons............................ Showers ( ) — Cafeteria Other fixtures, ( )---------------- Design Flpw.._:. gallons per per on per day. Total daily flow_._.__. w' ........gallons. � Septic Tari —Liquid ca.pacityl�C?_gallons Length ______________ Width................ Diameter................ Depth.___............ W Disposal T�.ench—No ... Lengthleaching Pit-No Diameter.... �_._...._. Depth below inlet____________________ Total leaching area..................sq. ft. Z Other Distribution tbox ( ) Dosing tank,( Percolation Test Results `=Performed bY.............,---- --- k='-••-•--•---•-----••-•------•-••---•---------._. Date........................................ W • Test Pit No, 1_____________'_mmutes per inch Depth of Test.,Pit.................... Depth to ground water........................ fX, Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground ater........................ ---------------------- -- ........... ld__ it ----- -•-•-••--•• -••••••----- - ODescription of Soil------_...�"� --- -_____ ___--__ ........... .+ / ...... .................................... W - � A r W , U Nature of Repairs or Alterations—Answer when.applicable............................................................................................... . .. - --.'------------•--...--•--•.--•--...__•__-�--•-----•--------------------�-�;.•..--P-----.•..•y...----•-----------------•----•--------.. Agreement: The undersigned,- ,,,agrees to install the aforedescribed Individual Sew e Disposal System in accordance with the provisions of iI .'s ` 5 of the State Sanitary Code—The undersigne �further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board *health. health. Si ......... / --'`. -...--•-------..`ff ..------•----- .!f r...../ .... Date Application A roved B ,f , , ----- :,--•..---.-_ Date Application Disapproved for the following reasons:="___.-.•.-..-•-------------•-------------------------------------------------------..__.....-----..._------ ..------•----------------- = = -----------------:-•-------------------- --•------;-----------------••-•--- Date PermitNo..................•-••-......-•---•--_.._..------------ Issued------ ................................................ Date 4 THE COMMONWEALTH OF MASSACHUSETTS ,�!!! ie f BOARD F.*HEALTH it -•- :... . .....OF......... -� ... f T rtifiratr of ( ourplittnrr ` THIS4CIFY, t. dividual Sewage Disposal System constructed ( or Repaired ( ) / Inst has been installed in accordance with the provisions of r Trrhe State Sanitary Code as odes ribed in the application for Disposal Works Construction Permit N d-' --.----- dated__- , 74 THE ISSANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A WA ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY r a v v� §..,+�' .5 .+,e"✓'i.r'' 'IYl4� '�5" .4 y„NaR +aN`,wfi 5:.:.µa,-.�.z� DATE.. >, Inspector yN `3J�uu'wlkk�4 i N.✓.'Weµ VMY-{<1sG'7i�i..NW�Y���w1.M�`�+n�.r::e�N�aL...h 4..:}. •:• � ,r � .. . CMS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HVALTH 71 - ........ No........l- ......... FEE.... t............... �t��tla�� >� , � �.un�trnrtilan �ernttt Permission is he y granted... --- ---...• t --•------------•------•-----------------•---•---------_____•---- ...................... to Construct or Re. tr ( ) n ndividuaI Se Dlsp System/ Street as shown'on the application for Disposal Works Construction Pe '"i No ated_._ Q Board of Health- DATE.__.. ............................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS. L:v G.l�1�"E:h.G>✓ ��I t._t*��=.j.>i. 97,5 ...,....."`_`.� r=LO,„/ k10 = 3' i F't�. �� �00 Oo 330,, i5o 0/4 r 4-9,6 P use- �oc7ca s��t_. . m� � • uSF Il>oo GAL_ Rev? t� SF x 2.S t �TS 44C $a CTCJ.+S/( OP_E A= SC7 S-. TOTAL -L->e;16W = 4Zc; -roTA L F'LQw = 33p &F..'D. rN f'. C Q Flop PEfZGDldT1G�tJ CZAT� : "IQ 2MIW, O¢ 1 �'ig rAk 4 p,� c�XR per Aw -. r 9z;.3 Zd p�'3 •,�� i t' Y aft . 1 �—�T' '-�j$jg0 �'6•, = Toll I:wo ., i.... �� K 4- =:Y 97 LOW -Roe ►uv S� SoI s. 4'Pam wv: GA,L. -Boy, �k•e S�rIC l 000 ;.,v, t►iv. S,��ro GpL. 9e.L Pit • Wiry-t .; WAS�IS�� r $TOE-7E= 90 U 1 'p C C,T17-►ED l.aU_Tlo� C��..12a/rt--.lam.. Q0 �A,IA I CGtZTtt=-r Tt-1AT TtAG 5ocp-uJ t-2E:F.'`b1�3 GC..�4�E'L�l�i WI'il-� TN` �ID�.Li►.�� �,,,�� Awr �.LT ?�tiCtG ftiG4Ui�CMtc�1Z:, of Tt-It oc= LE UAIrG tZCGlS l"LiZED U.1aG �UtVirY�}t-� Tt-CIS hs_A�� i; tJOT 01,4 AcJ o 11JSft:J:•n C_t.!i iiU, /t=�{ x• 'ftlt C�FC;i_:C�, j1 1Uwt T� AN t.f,y' C',C: U ,C +'y Tca l�C=_1 CC�/1r1 ►Jl_ LOT LO CATION -- � SEWAGE PERMIT NO. /�5 . VILLAGE _ ;`r 1 I N S T A LLER'S NAME i ADDRESS t UILDER OR OW ER� ,� (\ ell DATE PERMIT ISSUED oa-d DATE COMPLIANCE ISSUED G .. _ . [ I � I I 9 7 i i No 0190----- THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH 7z".".-.-... ..... OF. . . ........................................ Applira#ion for Dispooal Works Tomlrnrfion Frrmit Application is hereby made for a Permit to onstruct ( ) or Repair ( ) an Individual Sewage Disposal &Ie�w • -- .. - Locati Address --••o No. .. ._._... ..-. .............. •........ . .. .... ............... ow dress a f.......... ------------ �.:................ ....----....•--•------- Installer Address Q Type Building Size Lot./_.-�............Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow........... ... gallons per person per day. Total daily flow................ ��..�._..... .........................._gallons. WSeptic Tank—Liquid capacity,. `v'?gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench 2 N.o-. .. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No. / _._.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing �/ ~" Percolation Test Results Performed by... _,% ......... ,t.. ................ ...... Date_.. _. a Test Pit No. 1................minutes per inch Depth of Test Pit.____................ Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Descript'on of Soil - .. - .. -y=P!�� -' .............. . ... W •-••-----••-•---------------•-•-••.....•-•----•••••••-----•-------------•----•----•-•-••-•-•••---•---...•---•-•........_..........-----•------•-•--•-•--••••---•--.......•----••-••-----•---•-•--------. UNature of Repairs or Alterations—Answer when applicable............................................................................................... -•---------------------------------•-------•-----•-•-------•------•-•----------••----•--•-••-•-•--••-----•-•----------------------------------•••----------------•---....__.........................-- Agreement: The undersigned agrees to install the aforedescribej.Z Individual S age Disposal System in accordance with the rovisions of'I'LE p 5 of the State Sanitary Code— e undersi ed further agrees not to p ce the system in operation until a Certificate of Compliance has been i of health.Signe .... ...... ..ateApplication Approved By----•---•-• - ................... ...................... . Date Application Disapproved for the following reasons:........................ ......•.......•--•--...-••-•-•--•..............•........_........ --------•- . '.._ ...........................•----------------------•-----•----........--•-•--•--------........----------...---•-•----•-....------•----------------•---------------------------------------------....-•--- Date PermitNo...................................------••-•---......... Issued_--• ......................... Date N0 .1V.....s- .ST '' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,, �• .:' • ...... 0F...,�, .... . t. .... ......................................... AV irtt#i�an or Disposal Works Tonstrnr#inn thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ' .���... .................- ---- ........................................ f Loca�tiFgn Address r�" # ---'�f---9GYiA :{.. ............................................... ......-- ,=,f�1 '. .�.... ::`.'.�.:::':_...._ /.� N.,.:'X__ , -_E � Address f ' Installer Address d 6,4 Typ (of Building ° Size Lot �"'� ...Sq. feet Dwelling—No. of Bedrooms............ ""'_........................Expansion Attic ( ) Garbage Grinder ( ) `-4 Other—Type of Building No. of persons............................ Showers t� YP g ------------•-------------• P ( ) — Cafeteria ( ) dOther fixtures --- W Design Flow.......... '. ........................gallons per person per day. Total daily flow._._......- "e ......................gallons. WSeptic Tank—Liquid capacityl6r " allons Length................ Width.........._..... Diameter.........._..... Depth................ x Disposal Trench—No._.g.._.a ........ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No. __ . Diameter.................... Depth below inlet.................... �otal leaching area..................sq. ft. Z Other Distribution box ( ) Dosing n Percolation Test Results Performed b ... �. ...... .. t . Date.. J Y `f/ b+ �� Test Pit No. I................minutes per inch 'Depth of Test Pit.::......._.._:.:._ Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.......... Depth to ground water........................ oA ... ._. Description of Soil _ _ .Z > - U ......--- tt '�, b, ;� a'.,--------------------------- --•--- ------............. ---------_:........... W UNature of Repairs or Alterations.—Answer when applicable............................................................................................... =--------------------------•----......----------•-------•--•-------------........----.........------------.•--=---------------------------------•--------------------------------.._........-----. Agreement: The undersigned agrees to install the aforedescribed Individual $,"age Disposal System in accordance with the provisions of J iT LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health Igne n . ,D y Dater Application Approved By...........- .................... -- ......... Date Application Disapproved for the following reasons:....................... •---•--•----. .............. ---------------------•---•-------•---------...--•-••---•-----.........----------.....--------•-•---------'---------------------......._...--------------------------------•-------------................ Date Permit No..................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........7 (/ Ltrr ^t.........OF.:... .. + .... :.................................................. (�rr#i�irttiae of Tnrmplittnrr THIS_VISO S T F :;xThaf the Individual Sewage Disposal System constructed ( or Repaired ( ) by "" tr --.................. ... ,f� t l ... 24 has been installed in accordance with the provisions of T 5 of The State Sanitary Code as descri ed in the application for Disposal Works Construction Permit No....� -_--_ 6/0........... dated_.... _._A_1& ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------- - .2........ .................•------•---.......... Inspector............ .................. . --- ------•---•----•--...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD............. OF HEALTH .....O F............ .44'aL- !'l•.............................................. No.............t"4�.. �_71_op4j, .. . FEE... .`... i n tt1 park , strndUan panfit Permission 's by granted----- r- ......... to Cons t uct ) or . air ( � Individual Sewa isposal , yst , 3 r .> at No. � ,�` al - -------------G.C. G ............................................................. Street pp p cork Construction Per No Dated...../ ...... as shown on the application for Disposal l s µ - .- � DATE. ^ `J Board of Health -----------------•----........---..---' FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS LO,CaA�TION SEWAGE PERMIT NO• VILLAGE I N S T A LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 3��°4 `\ / 3\ �9 , zs' ys o o ���, �27 '[:T Fez T-Ic Aer,4 U C>C)U 77 PCxAL PR /7Z S- ni U�v=WAL-L AV G-G-1, LcC> S.F. t. CE)D 5'of=. E>o s.17--.-L;>. Tc>-I-,&L- Torn L 'C)A\k L-.>-( F7LOw 0- PU-:1-2C D L&T I C)LJ c) U-1 14 I= -It ti) -wv --77v= 4: q7. 11 15 LOAPO IWV. IW. GAL.4 Boy 96../ Sepric A, C� T-A k V- --f IWV. W. LsAr-H FIT sA \oV i-rW ST O"C- C-r--17-T t F- E ID TILC)'I P:�L- /S,." L-E-- LC)C-ATI 01-4 YZ V-a�I c I V4 E: ' PI-N-(G \AJ Tl,-Ai�-- 51 DE Lorr I 6o& C)i= T�4t:-.- L Lilt-) 2-4�r&t /ILL BAhTCIQ-- Z4- ok-4 A-6-1 kl