Loading...
HomeMy WebLinkAbout0068 FERNBROOK LANE - Health [68 JFernbrook Lane Centerville A= 208-085-015 =J�RECYCLFpCo2m UPC 12534 No.2153.3LOR iGONS���o� HASTINGS,MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name • / information is required for every Centerville V Ma 02632 12/22/2020 page. City/Town 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 filling out forms A. Inspector Information I I on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. dL P.O.Box 151 ray Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12/22/2020 Inspector's Sig ure Date 11 The system inspector shall sub it a c y of this inspection report to the Approving Authority(Board of Health or DEP)within 30 d ys of ompleting this inspection. If the system has a design flow of 10,000 gpd or greater, the ins ctor and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �n 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is Centerville Ma 02632 12/22/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems . Information on care and do's and don't's can be found at town health dept or mass.gov 2) 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 explain. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): ❑ 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) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �a 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 a septic 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. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® 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. ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts jn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available 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. ® 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts r� p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo-Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): min. 330 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped 2017 and pumped during inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? tank size Reason for pumping: maintenance 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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) ❑ Innovative/Alternative 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.75 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10 feet Comments (on condition of joints, venting, evidence of leakage, etc.): none t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 cam, Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo-Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet 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 Dimensions: 8'6"x5' Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 2° Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): baffles in place. no signs of major decay or cracks/leaks. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 cam, Commonwealth of Massachusetts !n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 P Y rY 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach,copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): Camera inspected no major decay or carry overs. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .� 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owners Name information is required for every Centerville Ma 02632 12/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leach pit cover dug up. 6'x6' pit with stone around it. current water level 3'4" below top of pit. no signs of levels being over current level. pipe to leach pit comes into the riser 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo-Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 yS 39 t4 G t5ins .doc•rev.7/26/2018 P Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 23 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: You must describe how you established the high ground water elevation: lot el. in area of leach pit. el. 40 bottom of pit is el. 30 low wetland area close by el. 16.4 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 68 FernBrook Lane Property Address Sounigo- Bellavance Owner Owner's Name information is required for every Centerville Ma 02632 12/22/2020 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 INVOICE' . CHAD HATHAWAY P.O Box 151 Forestdale Ma.02644 774 274 2581 HP51ONCAPE@YAHOO.COM INVOICE# 2047 Massachusetts DEP septic Inspector DATE:.12/22/2020 Title 5 Inspections—Emergency Services —Risers— Sewer Camera Inspections—Up Grades Pipe and D-Box Repairs-System locating-Well Sampling—Pump and Alarm repairs TO:DARZENTA 64 Arbor Ridge Plymouth DESCRIPTION HOURS RATE AMOUNT Septic Inspection and town filing fee 375.00 Paid with C.0 card M.0......................8319 TOTAL DUE 0.00 All work is to be completed in a workmanship like manner according to standard industry practices.Any changes or deviation to above specifications described above by consumer may result in added labor and or material costs.All payments are due upon completion of work.. Payments over 30 days Late will result in interest charges at the maximum legal amount by law. Authorizing Signature agrees to terms described above. Authorized Signature: Date: Printed Name Date: Please make checks payable to Chad Hathaway THANK YOU FOR YOUR BUSINESS! i Commonwealth of Massachusetts .. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address _ Daniel Kell Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for every page. City/Town 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: A. General Information When filling out forms on the computer,use 1. Inspector: I �� only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 run City/Town State Zip Code 508.428.1779 SI 12855 Telephone Number License Number B. Certification I 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 October 12, 2010 Job# 10-241 �ectorrsture 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. face Sewage , osal S stem• .a f 17 t5ins•09/0t3 Title 5 Official Inspection Form:Subsu g Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kell Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMFR ri5.303 or in 310 CIOR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank was pumped following inspection leaching pit was 1/3 full with no high stains. B) 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 explain. 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): l5ins 09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 • r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for every page. City/town State Zip Code Date of Inspection B. Certification (cont.) 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): ❑ 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) are 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 Isms-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for State Zip Code Date of Inspection every page. Cityrrown 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 a septic 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 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: 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for every 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. ❑ ® 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- 10,000gpd. ❑ ® 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for every page. City/town 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available 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 ® El 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 informatia.n. For example, u plan at the Board of Health. 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 Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y a 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No N/A Irrigation Water meter readings, if available (last 2 years usage (gpd)): System. Detail: Sump pump? ❑ Yes ® No Currently Last date.of occupancy: Occupied. Commercial/Industrial Flow Conditions: 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: !Sins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank punped 5 years ago. Was system pumped as part of the inspection? ❑ Yes ® No 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) ❑ Innovative/Alternative 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date: 1/2/85 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 2' Depth below grade: feet 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 Dimensions: 8.5' long x 5.2'wide- 1000 gal. 4" Sludge depth: 15ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 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 26" Y Scum thickness Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 101, How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank was scheduled for pumping following inspection Grease Trap (locate on site plan): 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 15ins•09108 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is required for Centerville MA 02632 October 12, 2010 every page. Cityffown 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 111 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is required for Centerville MA 02632 October 12, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): No solids or high stains present. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is required for Centerville MA 02632 October 12, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ 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 pit was found at 1/3 capacity with no high stains. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is required for Centerville MA 02632 October 12, 2010 every page. Cityrrown 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.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..'" 68 Fernbrook Lane Property Address Daniel Kelly -- -- --------------- Owner Owner's Name information is Centerville _MA 02632 October 12, 2010 required for ------------- - -- every page. City/Town 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 ❑ drawin4 attached separately ater \ \ ♦ \ ` \ " " " ervice 15 28 45 9 Fernbrook Lane Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is Centerville MA 02632 October 12, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20+ Estimated depth to high 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 of design plan reviewed: Date ❑ 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater map shows water at el. 20 and topo map shows property at el. 50. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 68 Fernbrook Lane Property Address Daniel Kelly Owner Owner's Name information is required for Centerville MA 02632 October 12, 2010 — every page. Cityrrown 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 j� Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i TOWN OF BMINSTABLE LOCATION (_08EernLroolc &., SSE#7 h 5 P. VILLAGE (reA e(_VJLe ASSESSOR'S MAP&PARCEL INSWAttEWS NAME&PHONE NO Ck.l C),,rLt(f Lldb.1,1-7 SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) ��`"9' (size) /OGY� NO.OF BEDROOMS 3 OWNER D,1,1( PERMIT DATE: C DATE A SP, 101010 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ""�/ \ \ 4 \ 4 \ 4 • ♦ 4 \ \ 4 ♦ 4 4 4 4 \ 4 4 4 4 \ \ \ \ • \ 4 \ 4 \ 4 h \ ' ! f f f f ! ! f ! f f I F ! ! J f I F f ! ! f f F I f I ! I F f F f ! h F4f�/kW f 4 �f4f4f h , IIJ ! ! ! l If FI Water - 4 . Service 1 5 28 45 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRNMENPfM,2AP'F RS v A DEPARTMENT OF ENVIRONII>h N},1]A�j RPT�ECTION r J u ! 2�8 MAP _ PARCEL V�� ©� _,-.•s I F f 7 U C - ' oO TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: f J Owner's Address12 -�� CO C�3� Date of Inspection: 7 Name of.Inspecto • lease print) i-��.J, Company Name: LQ o Mailing Address: Telephone Number: _ 2 g CERTIFICATION STATEMENT I 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 onsite 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 1 �4 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION (continued) Property Address: c c>,'— Owner: l Date of Inspection: Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: J, I have not found any information which indicates that any of the failure'criteria described in310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below. Comments: B. System Conditional) Passes: y y s 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 b the Board of Health P P P � , ill 'ass:, PP Y ,� .p Answer yes,no or not.determined(Y,N,ND) in the for the following statements..If"not determined"please explain. 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. ND explain: 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- obstruction is removed distribution box is leveled or replaced ND explain: 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)are replaced obstruction is removed ND explain: 2 Paee 3 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFIIC�ATION(continued) Property Address: f Owner P Date of Inspection: ' 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 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 surface water supply or tributary to a surface water supply. The system has a septic rank 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'ifthe well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 Page 4 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: •� Owner Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ �i/ 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 _ ✓ Liquid depth in cesspool is less than 6".below invert or available volume is less than-1/2 day flow 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. 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. _ 3/ 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 coliform bacteria and volatile organic compounds. indicates that the well is free from pollution from that facility-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.] (Yes/No)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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 the.system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone II 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. - 4 r Paee 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Pro pert Adodress: Ownser Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o 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 ? (/ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) V Was the facility or dwelling inspected for suns 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: Yes no m J Existing inforation. For example,a plan at the Board of Health. _ 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(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: a Owner Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_�' Number of bedrooms(actuaI): DESIGN flow based on 310 C 15,.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): . Is laundry on a separate sewage system (xe. or no): if yes separate inspection required] Laundry system inspecteli&lpable r no):: Seasonal use: (yes or no) Water meter readings, if last 2 ears usage(g d �J`"Z z �;?00 ( y g gP )) J� , ,. (� Sump pump(yes or no): /f n n Last date of occupancy: Gf Q,G'G I'2,6��&I)w COM I MERC AL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system.(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): "thei RAL INFORMATION Pumping Records Source of information: Was system pumped asyes or no): If yes, volume pumped: gallons--How was quantity pumped determined?,, _ Reason for pumping: TYPE F SYSTEM ptic tank,distribution box,soil;absorption system 2_ Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _.Other(describe): Approxi,�}ate ge of all components,date installed(if known)and source of information: �y Were sewage odors detected when arriving at the site(yes or n.o✓% Page 7 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM:INFORMATION(continued) Property Address: Jl� ql/ 4AJ� Own ' : J Date of nspection: BUILDING SEWER(locate on site plan)//X0_ Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain):;' Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) / Depth below grade: Material of construction: . crete_metal_fiberglass__polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certificate) .Dimensions: Sludge depth: Distance from top of I udge to bottom of outlet tee or baffle: Scum thickness: s �� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom ,f outlet tee or baffle: /l How were dimensions determined: ,( Comments(on pumping recommendations, ' let and outlet tee or baffle condition, structural integrity, liquid levels a elated to outlet invert, evidence of leakage, et .): tl GREASE TRAP.a(locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM PART C SYSTEM INFORMATION(continued) Property Address Owner r' Date of Inspection: TIGHT or HOLDING TANK(tank.must be pumped at time of inspection)(locate on-site.plan) Depth below grade: Material of construction: concrete _metal fiberglass__polyethylene other(explain):. Dimensions:' Capacity: gallons Design Flow:. gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: j Comments(note if box is level and distribution to outletYequal, any evidence of solids carryover,any evidence of eakage into r o of b x, c.): PUMP CHAMBER: locate on site plan). Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): r II 8 Paze 9 of 1 1 OFFICIAL INSPECTION FORM =NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: / I Owne Date of Inspection: SOIL.ABSORPTION SYSTEM (SAS):, locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries, number: Teaching 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, r ii i i CESSPOOLS (cesspool must'be pumped as part of inspection)(locate on site plan) Number and configuration: 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY) (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Paoe 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM FART C SYSTEM INFORMATION(continued) Property Address: Owner',- Date of nspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. i alloo ° 'on 10 Page 11 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propert Owne , Date of Inspection: l SITE EXAM Slope Surface water Check cellar Shallow wells ._. .. ;' Estimated depth to ground water Ijf feet Please indicate(check).all methods used to determine the high around water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: hecked with.local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Z'e © . 3 :� s 11 r s - - i P- IIC..i - R - -" - - to - - - _ C-II - — J .0 - r,- y: _ LEVEL !-: �:.r's^JjNi...-�'/��. ,: =i: _ C-O NIPUTA•7l IN .. -.. •.. M �ite Location: �� / / � C ®/� ��i �/� G�.� �' Lot No. Owner Address: '.Contractor: 01 G —,ddress• �JS—s .+9 S STEP cP I Measure depth to 1p/a-..., tale toMarest ,/IDAt. ..................................................................... .. .Da e w`= nonth/day/`/ear �. STEP 2 U g .Sf 1 Vila '!-tc -Ove! �-'an6E LGnc and Index VVe11 r%/lap loca_e _:.. ..__..._.. Site and dete!'ill.inc: ..,:.�,... ('A ��7pi'apl"IafE 11.^•dE::ZO tiPJE?1.................................................... I I i I - .03 Water-level range zwe .....................................................{ I " I , 1 ! j 1 j S i-P 3 Using rrionthl.y report Curre.it i r�faC^i hesource-s ondi tic I ; determine curl- ,It dept1h to � I 7 water ±eve: for index well ........................... I n o�tip/year Si" 4 L'jli'il Table of UAjcter-levei Adjust—ments I J for index well (STEP 2,A), currant depth j 0 water level for in -ex well (STEP EP 3), Ii and water=lev2 _one (S T—Ep 28) . determine watel'-level adjustment ..............:............................................................................ �� I 1 STEP 5 Estimate depth to high water by subtracting GCLIng the `Naar- level adjustment (STEP EP 4) from measured depth to water' va! at s e (STEP i 1-! .... �g la ....................................... Figure ..;.'-'ri.Jla�aw:t:.;l - 1117 Ciil 7silll. 15 :� 1, �rS._ : No. 9,w ev ._.'I 0 Fee 0 O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for IDiopoof *pgtem Cottgtruction Permit Application for a Permit to Construct( )Repair(+/)Upgrade( )Abandon( ) ❑Complete System ce,6 d vidual Components Location Address or Lot No. 6 14, Owner's Name,Address and Tel.No.�' >=��n�Orao�Assessor' Map/Parcel OR 5 Installer's Name,Address,and Tel.No. f Designer's Name,Address and Tel.No. 7 7/- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 0 9 Nature o Repairs or Al er ti ns(Answer when applicable) e S / 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 Certifi- cate of Compliance has been issued b his of H � Signed Date 9 leoel Application Approved by 1 Date G Application Disapproved for theroil—owing reasons Permit No. Date Issued Q D + i 1 f ' 14 No. �w '� _ Fee /o Q .-f • THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS ZippYication for Miopooal bpotem Construction i3ermit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) O Complete System l�"Individual Components Location Address or Lot No. /�� Owner's Name,Address and Tel.No. A sesso ' Map/Parcel ' O d).�Pr1�C 11 /1e Installer's Name,Address,an Tel.No. Designer's Name,Address and Tel.No. 7/j f Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) j Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature o Repairs or Al erati ns(Answer when applicable) e, �aC $•PAC //S/P D iQ -�D D /�aC � vCr'/ice 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 Certifi- cate of Compliance has been issued byAhis aid,of Signed Date Application Approved by _ Date Application Disapproved for the following reasons Permit No. G Date Issued 1910 u ——————=————————————————————————————————, THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comphance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired (- )Upgraded( ) Abandoned( )by at I el/w /©/el.I(" lti' �'�'y ��/�Ile has been constructed accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Uu`'I �11 dated V 1 1 v`r/ Installer Designer The issuance of t s pe6it shall not be construed as a guarantee that the st r►v ill unction as designed. Date u 1 I o l u Inspector !! No. Feet THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5po!gai *pgtem Construction Vermit Permission is hereby gra ted to Construct( Repair I/ U grade( )Abandon ) System located at ��i� red® , _ ��p eAr 1�,illcf and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special condition Provided: Constr ction ust Abe(completed within three years of the date o this pei t. Date:_._ , 5 r Approved by Septic Inspection Information DtaF.# fatee':.it3 cNti ........... 8/24/2004 ::::::::: .:::::::::::::. 2359 svrfuE 208y —� > ar:: l.:: 085015 jLati 1g ...... ►dd..r..::ss:. FFernbrook 168 brag ; Centerville 1.rxspc `: Robert J. Bortolotti ........................ 8/19/20074 >Crt # f ': 200 » Rep >l�v€ at .r':? C 1*t3",I 3t1II � .. 0 ...........................:...:.:::::.....:.::.::. I f , UO FIDs......... U. THE COMMONWEALTH OF MASSACHUSETTS BOARD -�OF HEALTH f 69s ...--...L?(.3".1....................OF....... ............................................... Appliration for Diovostti Works Tonotrnrtion Errant Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: .................................C �................... (I ................ . anon- d 'ess o Lot No. A� y . .1. .?�.. tJ.�. ....L`XL&.....�s�.... �r!!\C... ............. �_��`t'_.. v .............................................. Owner Address w2� .---.:. . ..._ ---.��1' ..............••.....................••---- -- -------------------------- Installer Address UType of Building Size Lot_- . ��..........Sq. feet ,� Dwelling—No. of Bedrooms.......................................Expansion Attic (�� Garbage Grinder (AJq Other—Type e of Building No. of persons r ................. Showers — Cafeteria VJ • a YP g P (a) a' Other_fixtures -------------------------------• . WDesign Flow.....3._��t..0.........................gallons per person per day. Total daily flow.............. ....................gallons. 1:4 Septic Tank—Liquid ca aci vjd.-"gallons Length...Z.4....... Width...4......... Diameter....4........ Depth.-.s.1--....._. W Disposal Trench—No. .... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing,..�tank _ Percolation Test Results Performed by--- X.T ....._�_.....A)V. ................ Date....... _71 J aTest Pit No. 1._4.. __minutes per inch Depth of Test Oit........l.;�n.... Depth to ground water...Mb..........._ . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ...................................I 0 Description of Soil...®.:. a-._....L.,.. �_x ... ..--5`-w`��`-- -•------------------ x --•---------_.Z` f --•-----C:_�? t _ _.. �`G�^^ � c- c>Vic- --. . -•-- ------•------•-•----------------- UNature of Repairs or Alterations—Answer when applicable...................................................................t......................... •-----------------------------------•---------------•-•--------••----•-•--------•---................----........-------•--------••-•---------------------•---•-•-----------------------................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenisissped by the board of health. Signed--..... J� --------------•-------•• ----- �r � J ✓G Date Application Approved BY...... =....................................................................... ...--•-----....�4 :-��•_ �� ............... Date Application Disapproved for the following reasons:............................................................................................................... ...............•-•------•---••-•---•---•----••-------•-•---................------•---...---..................................---....---•---••--•-••--•------•----...----------•-.....-----------••..-•--- Date Permit No....Iy:.. ..`.�.............................. Issued------....��__/6:- .��........................ 1 ---- ------- Date �� • No......................... FBI&—.................... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... . _ ..............OF Apliliration for Dhipa l Worlai Ton.ir union 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......-•----••.................................••--•---.....--------•--....••••................... ------•-••--....--•--------••-------••----••--•--•-•-•.....-••--.............--------•........._.. Location-Address or Lot No. ..........-•----...---................•-------.............-------•----.......................... --•••-------•--...------•---•......_..........-•--•-......••••--.................................. Owner Address W Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p.I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QI Other fixtures --------------------------•---.......-----...--------_.. W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... 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 tank ( ) Percolation Test Results Performed by---------- -----•--•--•--•-••--•-•------•-•-•---•------•------•---•--•--- Date........................................ Test Pit No. I----------------minutes per Inch Depth of Test Pit.................... Depth to ground water........................ �14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water____•_-_-_--_-__---_---. P4 ----- -•--•.................................................•-----•------------...---•----••----•---......................................................... 0 Description of Soil.................................................................................................... -----•--------------•-•------•----•--•-•--------•----•......---.--• -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLL 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. Signed...........--------•---•------------......---------r................................. ................................ Date ApplicationApproved By----------------- ............................................................. Date Application Disapproved for the following reasons---------- ----------•-----------------......----------..._..-------------------•----••-----•••---•------•---_._. ..............................------•---•-..._......._._.__._....---•------•---•---•----------•----•-•----...._...••---•-------••------------------------------------------------•••......--•-•-----••. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF.......................................................I............................. (Inxfif iratr of Toutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-•----•--•--•---•-•--•-----•------•--••---•-••.....................••----•-•--•---•-••---•---------- Installer at................................................................................................................................................................................................... --- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated---.-_-__--.--:--.--------_-=---•-----_--------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... ................................................. Inspector.... ----------------�-= •--• _... ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................I....................OF............--------............_._......._....---........................ No.......... ............... FEE................-------- Ubpwittl Morkii Tonu#rnrtion "rrntit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo....................................................................................................... ............................................................... ...................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated...... :........................... ---------------------------------------------•----------•---•---•-•-----•-•------------------•---•••----- Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN. INC.. BOSTON I` `,►w6i.E FAMILY �• � ►,10 6ARQlA•GE �jQ.11JD61Z. �5 � .• � �., C�A►►.�{ FLOW s 11O X 3 ' Z306•Ra 5EPTIG --4956.P. Q 0►'5Po5AL Pi t000 COAL. yj R-A W 5►DUWALL AILSA • Igo 5.c i 150 5.t. X a-5; s 3'15 G.PQ i BOTTOM AREAS . j�o 5�F•• f .4y so s.l%- x 1.o TOTAL DAI►-Y FLOW = 3306•Po- ` ♦r 1 • F'E2Go�ATIcN RATE+ i•'IN 2M1N o�L655 i ' ► FiICHi,FiO Pi TAR j 2411! �G�STIs� Q� le. `,p n re• �0 R � S TOP FNO• No►.F �-13-Bd .���`' (=•� 9 I oa �A. t_tS loco 11N. ID►6T. INJ. GAL. qg � Z• 6vK TAN► 1000 I NV. LCA�u • PIT INV. INV. i� w/ITW 98,'L 9s•1- CDA c� vJA,us;c 92 '� �ti� � "11•� 'y G 1c 2T I F I G►0 PLOT PLA`W OPILG w r-2-' NO SCALE SALE .�'-, depl PA.TE I �t wATta—. -vpvSau P>�.Ar i REF6SMNC& �. . I' 1 GE aTIFY THAT TN1"c Cau.�o%�-II:G SHovYN NEtZFsp t,1 GOMPti.`(5 yJITN Z Nt's S 1 oEL1N E L O 7"'" /f� y IA W 0 SET5AC. Rrw Q 0 '�-• � ZvWN OF �f3a�1���1f �3�-13 AMV 1S l�Gr" I, LOCA►TEO WITRI TN6 FLoop PLt>,.tN , NYC INC. REG I ST 6•7-6.w't.AU D S u IL �sYoe'S Tuts PL�.AI 15 Nat E3^`,r o .O d A W OSTrciUILLEr • MASS• i Iw5-T-RuMEWT. SvRVEY ( -TNE l.�+=FSE.'T5 6WOU0 b ' oT I E r'APP%- A..W' pf1.lAa ���-G'-f n � t•i 4 a 5"}{i d1 • ; t i`"• �•-s � 3 BS. _oil op BS8 9t fk 1 10 AOL -DWC1-'_, j lot. Afi J 0 to l.7 1 1 Pea' TA�Ww--' rr ►o, IA Pi TER �r o SULLI`JAPJ ' , 1•j A, No. 29733 BkXTER ��Q�ST�►��p� cSS�iJ:t.SI E`y�� � L O A 10N .. S E W A G PERMIT NO. c?� l �t'tcv��xd�� Lrnv� ' VILLAGE C'o"4r,-►�\i INSTALLER'S NAME V ADDRESS vvt�,z5 •�atiS wl�ll, I BUILDER ON OWNER C42. \ DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED l �d�k � � �� ��. .�,� �� � �� ��, -� �. ��