Loading...
HomeMy WebLinkAbout0195 FULLER ROAD - Health 195 Fuller Road Centerville A= 189 — 150 t 1 f UPC 12543. a Now L, �Posrco ° HASTINGS, Mai Commonwealth of Massachusetts ASSESSORS MAP NO foci Title 5 Official Inspection Form PARCEL 10: Subsurface Sewage Disposal System Form Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for State Zip Code Date of Inspection every page. Cityrrown Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: 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 State Zip Code Cityrrown S11285508-428-1779 Licennsese Number Telephone Number License 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 ` . June 9, 2009 In ector's Signature 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. V p ,am Title 5 Official Inspection Form:Subsurface Sewag isposal Sysl •Page 1 of 15 09-96 Avizonis.doc•08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for every page. City/town 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: ® 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: Tank is not in need of pumping at this time, Leaching system has no standing water or evidence of surcharge 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. 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 09-96 Avizonis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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: 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 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. 09-96 Avizonis.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 ❑ ® 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. 09-96 Avizonis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts NEW. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for State Zip Code Date of inspection every page. Cityrrown B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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. 1 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. 09-96 Av¢onis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for every page. Cityrrown 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? ® El information 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)] 09-96 Avizonis.doc-08/06 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for every page. City/Town State Zip Code Date of Inspection 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 0 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 Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Unknown Last date of occupancy: Date 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: Last date of occupancy/use: Date Other(describe): 09-96 Avizonis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is required for Centerville MA 02632 June 9, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Leaching system installed 5/18/07 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-96 Avizonis.doc•M06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Building Sewer(locate on site plan): 1' 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): 6" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) J If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------ 8.5' long x 5.2'wide- 1000 gal. Dimensions: 0" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 0" 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 Measured How were dimensions determined? 09-96 Avizonis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for State Zip Code Date of Inspection every page. Cityfrown 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.): Tank has liquid only, no solids. Liquid level was found at bottom of outlet invert. Tank is not in need of pumping at this time 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.): 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): 09-96 Avizonis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box (if present must be opened) (locate on site plan): OilDepth of liquid level above outlet invert 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 09-96 Avizonis.doc•M06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) 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: Type: ❑ leaching pits number: 3 Infiltrators. ® 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.): No standing water or evidence of surcharge 09-96 Avizonis.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): 09-96 Av¢onis.doc•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) 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. 3 19 23 9 r r r r r r r % rrrrrrrrrrrrrrrrrrrrrrrrr ,♦,�::r`r'ir`ir r r r r r r r r r r r r r r r r r r r r r r r r r ♦ ♦ , ♦ ♦ ♦ ♦ . ♦leleleeele , ♦ r`r`r`%r%`r`r'r`i ;,,`,♦,♦,`,♦,♦,,,♦, r r rrrrrrrrrrrrrrrrrrrrrr ` r'i r`r`i r`i r`r'r`r'r`r`r`r`r'r'r`r`i r r r r r r r r r r r r r ` ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r ♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦,♦i i r`i r`r`r`r`r`r`r`r`r`r` ar✓' ♦ �`(`i r ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ �N'ir r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r ♦,♦,♦,♦,♦t,�,♦,♦,♦,♦,♦,�,♦,`,`,','r'r`i r`r`r`r`r`r`r`r`r`r`r`r`r`r`i r`r`r i r`r`r `r`r`r`r`r`r`r`r`i r`r`r`r`r`r`r`r`r`r`i r`r`r`r'r`i r`r`r`i r`r`i r`i r`r`r`r ♦,♦r`r`r`r`,`,♦r`,`,`,`r`,`r`r`r`r`r`r`i r`r`r`r`r`r`r`r`r`r`r`i r`r`i r'r'r'i r%e% ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦,♦,♦,♦,♦,♦�,`r`r`r r r r r r r r r r r r r r r r r r r r r r r r r r % r r r r r r r r r r Water Service Fuller Road Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Fuller Road Property Address Liuda Avizonis Owner Owner's Name information is Centerville MA 02632 June 9, 2009 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 30' Estimated depth to 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 contour map shows water below el 20 and topo map shows property at el. 50. 09-96 Avizonis.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 i TOWN OF BARNSTABLE LOCATION diff c9l er \GJ SEWAGE# Mn 5 P VILLAGE U I Ikk ASSESSOR'S MAP&PARCEL RaSIA4,LER'S NAME&PHONE NO. r+(_L a I t L1 SEPTIC.TANK CAPACITY CD0 LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER Avvzonic, PERMIT DATE: C-�9Nffbb4Z-WE DATE`�5e ��Lqlnq 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 faci ' Feet FURNISHED BY � 3 19 23 9 t t t 4 t t t J J f f f f ! t 4 \ t t t t •. 4 4 4 4 4 4 4 f f f f f f f J J J I fJ f f f f f f J f f f f I \ \ 4 4 \ 4 4 4 ♦ t \ t t ♦ \ 4 t \ t 4 \ k \ \ \ ' t t ♦ t 4 t \ \ ♦ ♦ ♦ t \ ?s \; 4 \ 4 t \ t t \ \ \ ♦ \ \'t t \ 4 t \ 4 \ \ r t \ 4 t 4 t \ \ \ 4 \ 4 \ \ 4 \ 4 \ r \ 4 ♦ 4 \ \ \ t t t ♦ ♦,r r \ ♦ 4 4 4 t \ t \ 4 4 ♦ ♦ ♦ ♦ / 4 \ t t 'I 4 4 ♦ ♦ ♦ ♦ ♦ t t ♦ t 4 \ \ \ \ \ k \ \ 4 \ t 4 \ \ r 4, \ \ t \ 4 r t t t \ \ \ \ ♦ 4 \ \ \ \ \ \ \ 4 4 \ \ \ \ 4 \ 4 4 4 4 4 \ \ \ ♦ ♦ \ k \ \ 4 4 4 \ \ \ \\tJ(4 4 r �k�±[4 \ 4 \ \ 4 \ r ♦ r \ 4 4 \ \ ♦ ♦ \ ♦ r \ r r \ ♦ r k ♦ ♦ 4 t \ \ ♦ r r a a a a a a a a a a v a a a a a a a a a a a ♦ a i 1 l 4 4 Q TOWN OF BARNSTABLE LOCATION tul)e-( GOJ �I f SEWAGE# 2W7—Wd VILLAGE CPy��er y 1 �� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 1006 gcki l on5 LEACHING FACILITY:(type) '3— 365o 3911, }ors(size) NO.OF BEDROOMS OWNER LinAv'% (M s e PERMIT DATE: D 7 COMPLIANCE DATE: 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 sitetr 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, FA � ©OtC Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for �Diztl0 at 6p5tem Con5trUCtiott pertnit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System Lrl Individual Components Location Address or Lot No. lqr i✓r Owner's Name,Address,and Tel.No.Z44/� 191w;O2i 0 1lt, M4 �9rF�//ram AJ) Assessor's Map/Parcel Installer's Name,Address,and Tel.No.C �' ' / Designer's Name,Address and Tel.No./ ��+� �4�` �"'�' Type of Building: Dwelling No.of Bedrooms -3 Lot Size a�?7 `7�� sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ,3 341 gpd Design flow provided 3 7,13 gpd Plan Date y .17 4900`7 Number of sheets DateTitle S ��!'� h 07C l S �l '� 06 D ' /evision v ���o Size of Septic Tank %j pC� P&'-d ,JA,� Type of S.A.S. -I���y� 3Q529 Description of Soil � p 11 Nature of Repairs or Alterations(Answer when applicable) Rio- ( i P.- ,6A 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 B a of Si ed Date Application Approved by Date d Application Disapproved by: Date for the following reasons Permit No. �' Date Issued No. Fee 160 s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicAtion for �Digo5AY 6pMem Construction Permit + Application for a Permit to Construct Repair(�`Upgrade Abandon Complete System L'�Individual Components Location Address or Lot No. �gS /r Owner's Name,Address,and Tel.No.h'y* Assessor'sMap/Parcel �G, f0�, 7y�-y(-�jS` Ciil41,4//.r ml Installer's Name,Address,and Tel.No.315;r/T/O/)' � /-�/ Designer's Name,Address and Tel.No.Z a e-lff' Type of Building: Dwelling No.of Bedrooms 3 Lot Size F74 sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 7•3 gpd ' Plan Date 45 //1:900 T Number of sheets /evision Date Title S� �th 117 /'�� ��r'` ( �9 c�iAo Size of Septic Tankc l OCC e:* Type of S.A.S. 3 '�����yLrr 3052:) Description of Soil Nature of Repairs or Alterations(Answer when applicable) K-a?,, 11yC1165 /Yl- Ipt y 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 Boar. of Heal h. _ f Si ned Date �� C Application Approved by Date U Application Disapproved by: Date for the following reasons Permit No. � 0 Date Issued THE COMMONWEALTH OF MASSACHUSETTS " BARNSTABLE, MASSACHUSETTS -certificate of Compliance THIS IS TO CERTIFY that /the On-site Sewage Disposal System Constructed ( ) Repaired (1/) Upgraded ( ) Abandoned( )by 7`U/OT�t� i�J TY�.0 kk✓ at 1'95— A d .v ,Ile has been constructed in accordance with the provisions of Title 5 and the for/Disposal System Construction Permit No !P dated l Installer /�-ij�a��' �GU�T�yGt,dj Designer rP.. k_� in. —�e.�_t #bedrooms 3 Approved design flow 3y3 -1 / gpd The issuance of thisVP shall nnootj a onstrued as a guarantee that the system ill fu tion as,desi ned,Date I L/ Inspectors / i) ------------------------------------ No. =Zk2 l /- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migpogar 6pgtem Cr6truction Permit Permission is hereby granted to Construct ( ) Repair (v ) Upgrade ( ) Abandon ( ) System located at /9r yqillrr- 94 I't,7111alle 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 conditions. Provided: Construction ust be c m�plleted within three years of the d e of this p Date � / Approvy 0 i f Town of Barnstable Regulatory Services Thomas F. Geiler, Director Public Health Division +' Thomas McKean, Director 200 Main Street,Hvannis, MA.02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification_Form Dater Sewage Permit# ��Assessor5 Map\Parcel6 Designer: \ £ Installer: /�oi'�d�7��i, Address: Address: On '®-7 Jr /,a owj ). was issued a permit to install a (date) (installer") septic system at C( � F-C111&t ra- Cz W'l6 based on a design drawn by (address) +� datedahc (designer) 1 I certify that the septic system referenced above was installed substantially cording to the design; which may include minor approved changes such as lateral rel on ohe distribution box and/or septic tank. •• w M I certify that the septic system referenced above was installed with major c ianges (i.e. greater than I W lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow,-. ?� �,jH OF Af,%.cy �o DANIELA. G`m o OJALA CIVIL c (Installer's Signature) q No.46502 po�� GISTS � (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. iQ:Health/Septic/Designer Certification Form 3-26=04.doc ����. �o� �• �� GEC- �i� e>,�7` �/4-.vE y U6 Y P APW L O CQT_1.O N f ( SEW_ _6,C;-E_P_ER.MI_LUO., 1Us--T_ _ D h,TE_P_E_�2_N�1T 1_S SU E.D�= J - O AT_EiC.O M.P L_I_Q..NsA CE-1-SS U E0 __ r ;.� +' i � ` I .. F � .. __._ . t ..-.. . i Postal CERTIFIED MAILT. RECEIPT 0 (DomesticOnly; Provided) R.i For delivery information visit our website at u r-1 Er Postage $ dsj� �--�� p Certified Fee Qatk p Return Receipt Fee O�l`!° Irdo (Endorsement Required) O R., c%d Delivery Fee (Endorsement Required) JJ Total Postage&Fees $ ^J i G SIN Ln o �j u C en cc S YU A s S•-'Real -45,5&iP.ir. Ntreet,Apt ffZ::----------------- -�—-h —4 or PO Box NV 95 V �O City,State,ZI ... ...F............................. ----- e d t e rY; 4,4 c N)9 0a 1-,30'- :00 June 2002_ Certified Mail Provides:■ A mailing receipt (a-vana a)jooa ounr'ooee mod Sd ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. • Certified Mail is notavallable for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. • For an additional fee,a Retum Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and Ms. SENDER:COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signat 1e item 4 if Restricted Delivery is desired. X [ ❑Addre ■ Print your name and address on the reverse ❑Adressee ge so that we can return the card to you. B. Re ed by i Pti ed ame) C.Qe of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No Jucznas Mass., Real Estate Trust I 195 Fuller Road Centerville, MA 02632 3. Service type ❑Certified Mail ❑Express Mail I ❑ Registered ❑ Return Receipt for Merchandise I ❑ Insured Mail ❑C.O.D. 44 F 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article-Number (transfer from service label) R 0 0 5 ,116 0 ;0 0,0 0 ;019,1 2908 PS Form 3811, February 2004 Domestic Return Receipt 1o25s5-o2-M-15ao UNITED STATE Vfq< v 1LIrtif*ea 8 Z"°" �� e �r1 17 N6,i^h lam. ti:k,/�',�,}':. Y. Y"S. c,'4 4 la�"`. • Sender: Please print your name, address, and ZIP+4 in this box • I I I I PUBLIC HEALTH DEPARTMENT TOWN OF BARNATABLE 200 MAIN STREET HYANNIS, NIA 02601 � ltf���t,f�i�li,tii,��„,fl,I,►ifl�„ff,►,,,I�Jff���ll�„�f�f►f i ` Town of Barnstable CF THE Tp� ya ti� Regulatory Services snRxsrns Thomas.F. Geiler,Director i - 0.••� Public Health Division TFD MA'S Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 16, 2007 Jucenas Mass.,Real Estate Trust 195 Fuller Road .Centerville,MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system owned by you located at 195 Fuller road, Centerville, MA was last inspected January 24th,2007 by Patrick M O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of your septic system after further evaluation"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the,following: System is.in hydraulic.failure You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH D ARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHUSETTS u w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION OW / y TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 195 Fuller Road Centerville MA Owner's Name: Jucenas Mass. Real Estate Trust Owner's Address: Same Date of Inspection: January 24,2007 Job#07-15 t I - Name of Inspector: PATRICK M. O'CONNELL ' Company Name: SEPTIC INSPECTION SERVICES CO. 'i rsw3 Mailing Address: 189 CAMMETT ROAD r•` MARSTONS MILLS MA 02648 ` Telephone Number: 508-428-1779 - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inforrr�ation 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 O', j•G PA ILK .cn Needs Further Evaluation by the Local Approving Authority X Fails 01Co L% C i Inspector's Signature: YVI Date: 1/24/07 �F51 NSPEG�\��`�� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health o� DEP)within 30 days of completing this inspection. If the system is a shared system or has a design now 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: Liquid level in leaching pit is currently 6" below inlet pipe, high stain lines indicate pit has been full to top.Tank is structurally sound and can be used with a new leaching system. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. 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: 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. 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: f - Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 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 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 I 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X_ Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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 forma _Yes_(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—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. Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass.Real Estate Trust Date of Inspection: January 24,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks ? _X_ Has the system received normal flows in the previous two week period `' _X_ Have large volumes of water been introduced to the system recently or as part of this inspection '? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out _X_ _ Were all system components,excluding the SAS, located on site? _X _ 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? _X _ 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 _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/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): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_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) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed (if known)and source of information: 1970's Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_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: XX (locate on site plan) Depth below grade: 3" Material of construction:_X_concrete_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:8.5' long x 5.2' wide— 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 2" 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: 12" How were dimensions determined: STICK WITH HINGE FLAP. 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 has no evidence of leaks,has previously been full to top. GREASE TRAP: No (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.): Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 TIGHT or HOLDING TANK: No (tank must be pumped at tirne 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: No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: No (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.): Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_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.): Liquid level was 6" below inlet at time of inspection,high stains indicate nit had been full to top and is in hydraulic failure. CESSPOOLS: No (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: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 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 Fuller Road 25 49 48 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Fuller Road,Centerville Owner: Jucenas Mass. Real Estate Trust Date of Inspection: January 24,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: _Observed site(abutting property/observation hole within 1.50 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: A perc test will be performed prior to repair to determine groundwater elevation. No.-- ........ ............. . THE COMMONWEALTH OF MASSACHUSETTS �. BOAR® OF HEALTH ......V ......OF............ . ---.................------. Appliration -for Uhipwial Works Tomitrurtton Vrrtui# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -=77-M Z............t2 aLocati Address r t N we o _.' %_o ---------------------------------------- - �- Address n /� ----- --- =----- ----- Installer Address Type of Building T f'4 e T Size Lot_.VZ..?-- ...Sq. feet U Dwelling No. of Bedrooms-----.- _Expansion Attic Garbage Grinder Other—Type e of Building Showers — Cafeteria f-4 YP g ---•------------------------ No. of persons.-----�-------....------ �) ( ) Other fixtures .....v2----- -011a.3----------------- - 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 le chitin area.___.._.________Sq. It. Z Other Distribution box ( ) Dosing tank ( ) 6 6 � - rZ '77? Percolation Test Results Performed bY.......................................................................... Date--------------------------------------.. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..____-_-_______-.._.._. Gz., Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-_-:.___.___--__:_... ` . JJ - .......................................t...---------•-----F 0 Description of Soil---------------- 1 V� -----------2........... .......... - - 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 Article YI 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. r. igned ` D------------------ �`e Application Approved BY----------- ---- -•-•- . . --------------- j` -� --- Date Application Disapproved for the following reasons:-----•.............. ............ ---•------•------......•----------•----•-----•-•--•--------•-------•--•----- ................................•---•---------.........---•--------------•••-•--•----•------------------.........-•--•-•----•-------•---.........---------........__..........------•........------------ Date PermitNo........................................................ Issued........................................................ Date - --- - -- - �--- - -------------------------------- �---------------------------------------------------------- _ No FEIC IV ........ - .{ THE COM-MONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ----OF._.......... d ..:.. ------ d H Applirtt#iun -for Dispviial Works Tons#rnr#ion Vrrmi#`LL: Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: I Location Address t No. r uuo or , caner �� Address 40� Installer Address Type of Building :I- o14 /j'" Size Lot_._: ' ----Sq. feet U ( ) Garbage Grinder (Dwelling No. of Bedrooms_.... _�-•------------------------- Expansion Attic •) aOther—Type of Building --------------- ------------ No. of persons_________________ Showers O — Cafeteria ( ) Q' Other fixtures ... .'_--4_�?_V 4__.�_-_-_______ W Design Flow........................................ ..gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter---------.:----- Depth:___.___.....- E' x Disposal Trench—No. .................... Width_----------------- Total Length__________------------- Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below let...._. _-,.,,;,,,Total le liin area--___-._-._-__--_sq. ft. z Other Distribution box ( ) Dosing tank ( ) ,PA///^7 y a Percolation Test Results Performed by------- -----------------------------------------------------•--•-•--•-•. Date------------------------------------.--- Test Pit No. 1----------------minutes per inch Depth of Test Pit........._.......... Depth to ground water...__-.------__-:....... fX4 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ O Description of Soil----- ----------I , W ,�,x U -------•-------•------•----•---•-••----•-••------•-- --------------•------••••---•-••-----•----....--•-•-------------•---------•-------•------------------------------•-••••• i._.t----•--------- W --------------- -------------------------------------------------------------------------------------------------------------------------------- --------------- ----- :------------------------ x V Nature 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 Article XI 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. xigned.. - --------= *- 1-L ........................... r 1e Application Approved BY --,: _ _1� ;_. - - --=- - -- -----•------- ...-•-- y, Application Disapproved for f'li4 fofL owang rQasons: ______________ ______________ ._.__.__._.....Date_._-__________ 4, Date PermitNo:.`------••--•-----•••--•---••---•--•-•-••.............. Issued---------------------------------------••----------•---_ Date S „t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 'HEALTH x ............. ............................OF..... Apr#iftrtt of Tntt liana. `_„ x., .. j T TO C TIFY at the Indivi ual D``s'`osal System constructed ( or Repaired ( ) by..._...._.. ---•••- ....... . all r at--- __ --- ---- = ' -- -- --- -- • -------------------- -----•---.._._..._•----,_....--••-• ------ has been installed,in accordance with the provisions of Article I of The State Sanitary Code ,des gibed - the _ f application for Disposal Works Construction Permit No....... ......... dated...___ - __G ............ THE ISSUANCE OFT IS CERTIFICATE SHALL NOT•BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION F NCTION SAT ISFACTO RY DATE = . °l� . .. ---------------•------- Inspector I �-J ri t THE COMMONWEALTH OF M.MS6ACHUSETT'S BOARD OF:�HEALTH OF ` ' FEE..___ _.,,_,Permission i eby granted---- - ----- -- -------------------- .............................. to Construct or Re (. ) n Indiv' ua Sewag isp }}Fstem at No.-r-. ----- ----- Str z 7 y- as shown on the application for Disposal Works Construction P o..... D d ..__.._ ..................... Board of Health r DATE... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r I _ e -3' ;, yk A4:Q1 T 4 0 0 f� wN SYSTEM PROFILE NOTES _ LEGEND SYSTEM DESIGN. TOP FNDN. AT EL. 59.16' , ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) Great Marsh ACCESS COVER TO WITHIN 3" OF FIN. GRADE 1. DATUM IS ASSUMED 100.0 PROPOSED SPOT ELEVATION GARBAGE DISPOSER IS NOT ALLOWED / AccEss COVER (WATERTIGHT) To WITHIN 6" OF FIN. GRADE Route 28 28.0' MINIMUM .75' OF COVER OVER PRECAST /� 2z SLOPE REQUIRED OVER SYSTEM 2. MUNICIPAL WATER IS AVAILABLE DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD 56.5 100x0 EXISTING SPOT ELEVATION - RUN PIPE LEVEL 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. - 1 USE A 330 GPD DESIGN FLOWz" DOUBLE XTI WASHED PEasTorlE I_ focus FOR FIRST 2' OR GEOTEXTILE FABRIC I 100 PROPOSED CONTOUR 46.0 2 660 EXISTING 1000 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO e SEPTIC TANK: 330 GPD O = GALLON SEPTIC 55,0't* �13H- 10 100 EXISTING CONTOUR USE A 1000 GAL. SEPTIC TANK (RE-USE EXIST.) jiq TANK (H- 10 ) 53.5' 53 58 go z.o' o 4 RE-USE BAFFLE 53.75' ,4 51.5' 5. PIPE JOINTS TO BE MADE WATERTIGHT. � LEACHING: 6" CRUSHED STONE OR MECHANICAL 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH �o`P SIDES:2 (29.7 + 10.25) 2 (.74) = 118 GPD COMPACTION. (15.221 [21) 3/4 To 1 1/2 DOUBLE WASHED STONE MASS. ENVIRONMENTAL CODE TITLE V. 50 ; BOTTOM 29.7 x 10.25 (.74) = 225 GPD DEPTH OF FLOW = 4 ( 3. c SLOPE) (-!-X SLOPE) TEE slzEs: 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO TOTAL: 463 S.F. 343 GPD BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. INLET DEPTH - 10" - USE 3 3050 INFILTRATORS H-10 OUTLET DEPTH = 14" 5.3' 8 PIPE FOR ,SEPTIC SYSTEM TO SCH. ;40-4" PVC. WITH (4� STONE AT ENDS AND 3' AT SIDES f FOUNDATION EXIST. SEPTIC TANK 37' D' BOX - 10' LEACHING 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. LOCUS MAP MA 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING NOT TO SCALE APPROVED DATE BOARD OF HEALTH DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION BOTTOM TH 2 EL. 46.2' OF ALL .UNDERGROUND &- OVERHEAD UTILITIES PRIOR TO ASSESSORS MAP 189 PARCEL 150 COMMENCEMENT OF WORK. 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND THE INSTALLER SHALL CONFIRM MIN. SEPTIC TANK SIZE AT 1000 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE TEST HOLE LOGS ALL BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING GALLONS AND ITS SUITABILITY FOR RE-USE . REMOVED 5' BENEATH AND AROUND THE PROPOSED I ANY PORTION OF SEPTIC SYSTEM LEACHING FACILITY. ENGINEER: DAVID FLAHERTY, IRS WITNESS: DON DESMARAIS, IRS DATE: MARCH 22, 2007 PERC. RATE _ < 2 MIN/INCH CLASS I SOILS P# 11686 f ELEV. ELEV. p" 56.7' on 56.7' A A LS LS �6,64 9" 1OYR 3/3 12" 1OYR 3/3 k�k B B LS LS X 5 56.17 31" 10YR 4/4 29" 10YR 4/4 54.3' 54.1 o SHED �� k . CO' X 7.13 -/56.37 56.21 k I } S C C +aQ.57 PERC 56.69 _ _ - --F _ - _ _ _._v<- CMS _.: = CMS +56.53 , , GARDEN TEL RISER }-5s.��. _ 56.04 10YR 5/6 10YR 5/6 -5fi26---+I 6.41 --56-50__.-- �56.66 75�52 i RHODYS `\�'56.40 �TH-1+56.50 56.12 +56.04 / LP 1 -56.28 - GRASS 55.69 DRIVE: GATE x � L 56.51 '----_,_ _ 126" 46.2' 120" 46.7' 8 TH-2 56. 55.46 f. �'� `---F56.56 �+56.1 �s.so 55.52 NO GROUNDWATER ENCOUNTERED 56.0 F56.58 �. 6.30 x 56 *56.67 DECK y-56. 2 �. �-9j ry �53 \\S 56.99 58.26 x 56.98 ^ x TITLE 5 SITE PLAN 56.80 BENCHMARK 5 .9, �� �� ' of COR BULKHEAD 4 x ELEV=57.7' 55-52 EXISTING 195 FULLER RD. O) 57.03 DWELLING 57. 1 I 1 ^� x GAS TOP FNDN=59.16' h� (CENTERVILLE) BARNSTABL:E, MA METER 5 .15 1 5 31 *55. 56.59 s7.48 PREPARED FOR BORTOLOTTI CONSTRUCTION/ X PAVED '� + 4.91 88 O i DRIVE f LINDA AVIZONIS 56.03 O 56.27 ,1 `o`Z1 4.89 x DATE: MARCH 28, 2007 ' GUYWIRES 55.35 1 , 55 . 7 27,744 SQ. :FTf X 0.64 ACRESf 55.4, 54.82 ' �5�3.48 54.98 � `•_� 1 0 I *54.28 + Scale: 1"= 20' G S O - 54.46 -I-54.40 5.35 0 10 20 30 40 50 FEET x 0;k1D 111 , 11 off 508-362-4541 X � I fax 508 362-9880 0355.09 d o wry cope erg g ire e erir? g, Inc. N OF Mass ,�'CW b���� q a ARNE H. ti� AriN Cl VIL ENGINEERS OJALA W CIVIL - L A ND SUR VE YORS Street - YARMOUTHPORT MASS. :. DA FS �sT . O � . , 939 Maim , S/CN4L DCE #07-036 07-036 BORTOLOTTI_AVIZONIS.DWG (DDF) r - I N S " u lk�Kt,{,. &a . //%/�• .w. l r $ �` o �'d:' s ,es u'I,; ,,.:.rfz,. /r o + E ff 1 ^ t THE COMMONWEALTH� � L OFM SAC TSETTS BOARD , ..�t, -------OF......�0 qS EP� Z Apphration -for :41-Ativiial Worbi Tutuarurtion Vrrnift Application is hereby made for a Permit to Construct or Repair an Individual Sewae Disposal PP g ( ) P ( ) b P System at: ./fit .._.-----'------�%�C .' frX ) ./.......... ....................';-----------._...._.........._... L aeon-Add ss 7 I-,/_o�Lot o. , •----------•------------------ f `l -�-da . N Ow r Address a -_-------------_----------- 6 �� . ------ ------- ----------- -------- -----------'---- -- ------- --- ---- ---- -- Installer Addr s Q Type of Building Size Lot.j,,.R__' Sq. feet Dwelling—No. of Bedrooms..._..13_._ .Expansion Attic ( ) Garbage Grinder ( `) i a Other—Type of Building s No. of persons.._3_____________________ Showers Cafeteria ( ) Q Other fixtures __.._ -_.._ -------------------- W Design Flow.................... ------------gallons per person per day. Total daily flow---___----- ..._.gallons. WSeptic Tank—Liquid capacity-t'"''Vgallons Length_! :�'... Width. ----`�-- Diameter................ Depth___.-..___----- x Disposal Trench—No..................... Wid -.._.-i-------_._.__ Tota th .............._. Total leaching area--------•.._._.-----sq. ft. 3 Seepage Pit No..../ ---. Diameter--� _ ept elow et. - --- Total leaching area-----------------sq. it. Z Other Distribution box ( ) Dosing tank ( ) " 6 17y. ~' Percolation Test'Results Performed by.......................................................................... Date-----_----------------------._.-----._.. W Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...-----__-_.-.-._---.._ (14 Test Pit No. 2-_-_-____-____minutes per inch Depth of Test Pit_________________ _ Depth to ground water........................ - .. . O �` - Description o oil--.--="'---� a�-----•-- i1a� ` ` - .:.-.. X...V -------------- - ----•--. -•--- ------------•--------_-.----------•-----------.-_....----------------------------- W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature 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 Article XI of the State Sanitary Code—The undersigned further agreesn - not to place the system i operation until a Certificate of Compliance has been issue�•by the boar of health. igned--- 4.4 .... /) Ls!! °�-�$ .. Date Application Approved By .._._ G/.._>�%: /te D . Application Disapproved for the following reasons------------------••----••--•--•---•------------••------•----------•---._.....--•---------------•--...----------- ----------------------------•---------------------------------•-•-------------•-----•---------------•---•--------------•----•-------•-•--- ------•--------•-----•-------------------.----- Date <�Permit No. ------------------------------'--'----....:. Issued..... ----- ----------- Date k. 1�t�� i No_'.... Fss...... .. TH1r COMMIONWEALTH OF MASSACHUSETTS BOA=R D ff �EA OF.` A.Ppliratiuu -fur' - iavmal Works Totu�urtivn Vrruift Application is hereby maald for a PermRt to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a �tr L anon Ad s .5 ------------------------------ ----—-- --- -•t --_------- d Y���J�y�" Address „ _.................................................................................................. .......... .........! ...........__..::...1.__.____ ...__.__._.__............................_ Installer Addr ss Q Type of Building Size Lot...y R�.__.... ..Sq. feet Dwelling—No. of Bedroom __________ _______ ______________Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Buildin "_..- _ YP g ------------ No. of persons---3--------------------- Showers (A) — Cafeteria ( ) Q' Other fixtur W Design Flow...................... ................. gallons per person per day. Total daily ow-------------a......... _--. --.._-___gallons. WSeptic Tank—Liquid capacity_`. gallons Length__ �__------- Widtl ....... . Diameter________________ Depth..._-__-_-_--- x Disposal Trench—No- --------------- ---- Wid ------------- ota ...._..._------ Total leaching area--------------------sq. ft. Seepage.Pit No....�` �'____ Diameter.... ............. ept e ow . et___. _.___._.......... Total leaching area.___-.-._ .____..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) &A 17Y- '-' Percolation Test Results Performed b _______________________________________________ Date.___._.__...___._..:._____: a' Y --------.--- i� Test Pit No. 1----------------minutes per inch Depth of Test Pit..................... Depth to ground water................__--.--. t4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground x � { water________________________ DY escrvtio � Soil--------- ' i -------------- .._.._.... ---- -µ---••---•--x - U Nature of Repairs or Alterations—Answer when applicable.-.____ _______________________________- ..___._________. -----••-- -------•-•-------------•------------------------------ Agreernent: The undersigned agrees to°install the aforedescribed 'Individual Sewage Disposal System in accordance with the provisions of Article XI 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 boar 'of heap ` SignedA t Date Application Approved B a . -�. .� ;• ": t � �._ ���- -'.ate �/ s Application Disapproved for the following reasons:..__.. _________________________ ___............ _.... __ -------- .................... ................................................... ..................................... Date .5 Permit No......................................................... Is ...... • .......................................... Date ' THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEAL. .........OF....4"4�. AOL...�. .............. err#if irate of G.Wmpliatta �,�.THI S T CE " IFY, Tha Individual Sewage Disposal System constructed or Repaired ( ) bY---l........._ 4 -- -------------------- --------- - ------ -- •-•------------------- ....., installer has been installed in accordance with the provisions of Article o he State Sanitary Code �s described in the r/ // application for-Disposal Works Construction Permit No______________ _ "`"_- daftd _r __S. --j� .............. THE ISSUANCE.OF,THIS',CERTIFICATE SHALL NOT BE R'MED AS. A RANTEE THAT THE �.S�ISTEM WILL FUNCTION SATISFACTORY. DATE. Inspecto ------ ----------- --•-•-•. .. ..... ------..._....,:: THE C'OM140NWEALTH. OF MASSACHUSETTS BOARD O HEALTH / No.....( ------ FEE ...................... i� 4L)Tstrurti hermit - Permvo s hereby granted:!'. _.....------ jA----------------------• ..' to Con t ) o>; ljlepair ( ) an Indiviidua e D a] S em .at No --------/-1't'ti !' ...../-.........J//---Y ........................................... • ~ - _----------•- ,: - ��R��;Street ,,yy as shown on the application for Disposal Works Construction P -;it No _:.__._ ___. Dated_13..._7t._`............. F. .. .----- - .. ----------•---•-----_ • ._ _ s- t / h.. - o r2._:;F - Board o£ Healt _______________ DATE. .... ........... . .. FORM 1255 ORBS & WARREN. INC.. PUBL SHERS - .'... ., y �r 4 ; y. . ... . _ . _ .. No ................. Permit for .................... n v ........ Location .......................................... ..: u r.. Owner .. .. ... Type of Construction ......:................................... . o .. ...... . ....... ... .. .. Plot .......................... lot % � . Permit Granted .. ...................... ..............19 Date"of Inspection .;. 19 N Q Date Completed .. 19 ( �} !� PERMIT REFUSED .. -•� ................., ... 19 ....... ..... ........................................ ................................................... 11 p ............................................. -- i Approved , cY ... 19 s yg