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0030 GLENEAGLE DRIVE - Health
30 Gleneagle Drive Centerville P A = 191 164 IN I UPC 12543 a�a No.,_,...53L HASTINGS, MN DATE 5/17/06 PROPERTY ADDRESS 30 Gleneagle Drive Centerville MA 02632 _ On the above date, the septic system at the address above was Inspected. This system consists of the following:... 1. 1-1000 gaeeon zept-ic tank.,. !" 2.- 1-Di31-aigat:ion Box.+ 3., 2-500 ga e Pon ieach.ing chamge2.6., Based on inspection, I certify the following conditions: 4., 7h.is .ins a 7.itie Five zept.ic 4yztem., 5.� SeRt.ic byztem .iz in PaoRez woak.ing o zdea at the p zebent t.ime.1 _ SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc, Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 E' CP. MACOMBER & SON, INC.anks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections 66 Centerville, MA 026.32-0066 775-3338 775-6412 -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: .. 30 Gleneagle Drive Centerville MA 02632 Owner's Name: Melissa Cotton Owner's Address: 197 Mystic Drive Marstons Mills MA 02648 Date of Inspection: 5/1 7/0 6 Name of Inspector: (please prints Robert A Paol'ini Company Name: 7_ P.Pacom&e2 Y.Sion 1ne. Mailing Address: Cen eay.� e, usz.-02632 Telephone Number: 5 0 8-7 7 5:3 3 3 8 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 on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15:340 of Title 5(310 CMR M000). The system: XXX Passes — Conditionally Passes Deeds Further Evaluation by the Local Approving Authority F Signature.,., `l ° Date: Inspector's gnafore 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.Ifthe 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 diffcreiit conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 Gleneagle Drive Centerville MA 02632 Owner: Melissa Cotton Date of Inspection: 5/1 7/06 Inspection Summary: Check A,B,C,D or E/ALWAYSveomplete all of Section:D A. System Passes:YES NO 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: Septic Zyhtem .is .in R2oRea wo2k.inq ozdea at .the pzezent time B: System Conditionally Passes: NO One or more system components as described in the"Conditional Pass".:section need to?P.replaced.or repaired.The system,upon completion of the replacement or repair,as approvfd�by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following siatements.If"not determined"please explain. NO 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: NCI 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 distrilution box is leveled or replaced ND explain: NO 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: hr 2 . r Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 Gleneagle. Drive Centerville MA 02632 Owner: Melissa Cotton Date of Inspection: 5 1 p 6 C. Further Evaluation is Required by.the Board of Health: NO Conditions exist which.require further evaluation by the Board.of Health:in order to determine if the a 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: no Cesspool or privy is within 50 feet of a surface water no Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh e. . 2. System will fail unless the Board of Health(and Public WaterSuppher,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: no The system has a septic tank and-soil absorption system(SAS)and the SAS is within 100 feet.ofa surface water supply or tributary to a surface water supply. 40 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. rc o The system has a septic tank and.SAS ancfthe SAS is within 50 feet of a private water supply well. n o 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 v-.-3ua-e 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: ,k 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION(continued) Property Address: 30 Gleneagle Drive Centerville MA 02632 Owner: Melissa' Cotton Date of Inspection: 5.11 7.1 Q 6 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 _ -7 Discharge.or ponding of effluent to the surface.of the.ground or surface.waters due to an overloaded or X clogged SAS or cesspool 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'/2.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. , 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,4vater 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 forT.4 NO (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 1.0,000 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. 4 Page 5 of I 1 OFFhCIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 Gleneaale Drive Centerville MA 02632 Owner: Melissa Cotton Date of Inspection: - 5/1 7/0 6 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) A. X _ Was the facility or dwelling inspected for signs of sewage back'bp 0 _ 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)] 5 Page 6 of 11 OFFI:CIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S .SUBSURFACE SEWAGE DISP..OSAL SYSTEM,:INSPECTION FORM � PART C SYSTEM INFORMATION Property Address: 30 Gleneagle Drive Centerville MA 02632 Owner: Melissa Cotton Date of Inspection: 5/1 7/0 6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . 3 Number of bedrooms(actual): 3. DESIGN flow based on 310 CNIR 15.203(for example: 110 gpd x#of bedrooms):3 3 Q. Number of current residents: 0 Does residence have a garbage grinder(yes or no): n o Is laundry on a separate sewage system:(yes or no): n o [if yes separate inspection required) Laundry system inspected(yes or no): a o Seasonal use:(yes or no): .a 2004_4 3, 000 ga_,�,eons gPD=117.41 Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 5=7 5. 0 0 0 ga e e o rz z G%D=2 0 5 4 8 Sump pump(yes or no): Last date of occupancy: unknown COMMERCIALaP6USTRIAL Type of estal 3 rrWnt: N 14 . Design flow gpd Basis of d6sign''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 — Source of information: NIA Was system pumped as part of the inspection(yes or no):_r a.6 If yes,volume pumped:_LD QQgallons--How was quantity pumped determined? e a.s u 2 e cl Reason for pumping: &aa ;„f 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: 6 yeazh.., new, .9each 9128100 Were sewage odors detected when arriving at the site(yes or no):n Q 6 Page 7 of 11 _ OFFICIAL INSPECTION FORM—NOT FOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 Gleneagle Drive Centerville MA 02632 Owner: Melissa Cotton Date of Inspection: 5 T1 7/06 BUILDING SEWER(locate on site plan) De th below ade: 22 P t�' Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: 2 0 f Comments(on condition of joints,venting,evidence of leakage,etc.): ao.intz appeal t-ight.� No 2eakaae.� Vented thaough horina »ent., SEPTIC TANK:e,3(locate on site plan) f 0 0 0 ga e i o n1s Depth below grade: 16" Material of construction: X concrete_metal_fiberglass polyethylene other(explain) r no : attach a co of age confirmed b a Certificate of Com lianee es o y If tank is metal list age:— Is g y P (�', ) —( P certificate) Dimensions: 8' 6"X5'.8"X4' 10" Sludgedepth: 4aace Distance from top of sludge to bottom of outlet tee.or baffle: tea ce Scum thickness: t z a c e Distance from top of scum to top of outlet tee or baffle: t as ce Distance from bottom of scum to bottom of outlet tee or baffle: t/2Qs e How were dimensions determined: mea.6u2ed Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,.evidence of.leakage,etc.): — um tank eve :in /r.Paceo an zh 2uc u2¢ y .3ourz GREASE TRAP:NO (locate on site plan) Depth below grade: Material of construction: concrete metal f berglass_polyethylene—other (explain): — — —fiberglass 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.): G/teaze taap .iz not Raezeat 0 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: 30 Gleneagle Drive Centerville MA 02632 Owner: Mt-1 i Gaa rattan Date of Inspection: c;.l 1 7 /n ti TIGHT or HOLDING TANK: NO (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.): T.iahf nn hnOr/izi fnn/rb n4Q nnt aZa694 - - DISTRIBUTION BOX: Y e Aif present must be opened)(locate on sitd lan) �. ,v 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.): - /3ox .iz ievei., fla.6 I eatezae., .e.id, 2,2; : oaaQz-' No leakage .in o2 out o ox,, . 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.): Pump chamgea .iz not /2a9zent 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 Gleneagle Drive en rville MA 02632 Owner:. Melissa .Cotton Date of Inspection: 5/1 7/0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located see 12age 10., Type leaching pits,number:_ X leaching chambers,number:2 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 poriding,#mp soil,condition of vegetation, etc.): Loamy to medium zand.,No z.igrzz o� Nond.ing., So.iz e a/te 2y.' Vegetation i.6 no zma-e 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.): Ces.612oo:e,6 ate not 121tezent 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.): P2.iyy .ib not P/Lebent 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 Gleneagle Drive Centerville MA 02632 Owner: Melissa .Cotton Date of Inspection: 5/1 7/0 6 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or bencli%narks.Locate all wells within 100 feet. Locate where public water supply enters the building. R 9 f112 le /�- 9 � f 3 3q 6 a3 . A -q Sy -y a9,� 00 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: 30 Gleneagle Drive Centerville MA 02632 Owner: Melissa Cotton Date of Inspection: -S/1 7/0 h SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to groundwater feet Please indicate(check)all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If checked,date of design plan reviewed: u e.6 Observed site(abutting property/observation hole within 150,feet of SAS) Checked with local Board:nf Health-explain:a.A �u i P ca2d no Checked:with local excavators,installers-(attach documentation) Accessed USGS database=explain.AttR r t own.-&aznista& 2e. me—,u¢ You must describe how you established the high ground water elevation: 11,6ed r Cape Cod Commis.ion ldatez 7agie Cohtouz.s And l uatie ldatez Sul?p2y Oeii head Raotect.ion�azeah map., Sept 1995 IUatez aezouzceh o-14p.ice cape cod commi,6.40n Leaching Pit sect Groundwat Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. . 11 ' TOWN OF BA TA IIOAIiU OF UBA1.'�11 •rMnn rw'rn""rr y M It�gPFCTION FEMM - KART D•r CBRTfF1CA�'��? _;3UnSURFACR .FWAtiR 1)181'USA4 t1Y8TE ..,,, sm ..�„-,,,.n,.-.�,. ,,,M++�•�,+�' ''""'e"'�.'�r`T-,R.� -TYPE Olt PRINT CLBARLY- PROPERTY INSPECTOO Q2nLery0.2632 STREET ADDRESS 3fl :G ASSESSORS MAP, IILOSK AND -PARCEL S', Melissa._ otton' OWNER's NAME .• • .. . PARR D CHRTIFSCAT30N NAME 'OF INSPECTOR Ro ose h :P., Naco►n4e2 -` Son Irtc COMPANY NAME , Box 6 6 " 'C�n �?v i 2 2e Ma ab' 0z6 To or city. StaLt tiP COMPANY AM OS. str• �' , FAX 1',508',1790 - f 578 . COMPANY TELL�PHONE ( 508 17.5 - 3338M. cTuvrI'FICATION. STATEMENT I. certifY that I ha e P ersonal'lY i,ns'pected .the Qew�ge diAPosaandyetem at this address and that the informatioon'rT erinopeoti*newag'apertorrmed and any omplete as of the time ..a,R �inspeeti n. and tnaintenanee of on- With regard.i»g upgrade�� .ma•intenae�e�u abd nctionpalr •are• aonqis'tent "recommend and expe-'fence in th@ PrOP with my traini�tg a . site sewage disposal. systems • , Check one: _ • Syste� PASS*D , ne ection which► •I have ..conducted hasadeuately. protect�publian The i P which indicates that the system' fails to Any fAilu•re }jeR.lt}i or t}ie envi.rOpment as defined d in the FAILUR�SCRI'PLRIA :BEQti071 o:f criteria Dot evaluated are as stet this. form. System FAILED* .. Which ,I Nava 'oondll�ted '}1ae . found that the System fails tQ The inspec•tiori twith ec.t the public health And tho eny4rQoted on�PA'EtT Cd- . FAILURE Title . prot 303 , and as • speci f ieally n . 61 310 CMR 15 � ' CRITERIA of this inspection form. - Date Ins-pector 6igneture must be rovtded 'to :the .OWH9R•, �. BUYER'- of this certaf�hj D9ARD ou HEA 11 rn" coFY ..re aysPii.oabl� ) an . , • „r�.� * If th e inapect$on FAILEb.+ the .owners' •oeationatunless. allo�wedaartrequi,•re�d - within th in o'ne year of the da't•e of the ep ithin o'n tsa urovided in q110 OMR' 151305.1. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP ' h d PARCEL ti ►r.�ewanp LOT0 TITLE 5 [SSESSMENT CEIVED OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYSUBSURFACE SEWAGE DISPOSAL SYSTEM FO R U 0h04PART A OF BARNS1*ABLECERTIFICATION EALTH DEPT. Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner's Name: SCOTT LEGER Owner's Address: 30 GLEN EAGLE DR CENTERVILLE 02632 Date of Inspection: 2/11/04 LOFY Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 perfonned 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: X Passes _ Conditionally ses _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: Date: 2/11/04 The system inspector shall submit opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect§ n. 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 SYSTEM PASSED TITLE V INSPECITON. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. T:rlo r Trya— +;nn Fnrm r,i1 Si?nnn Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECITON.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 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. _ 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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 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 '/2 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 NOT IN THE LAST YR. 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 l 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 form.] NO (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 X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X 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. a Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 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)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 0 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents:3 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): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):— Sump pump(yes or no): NO �a —� S 000 Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YR Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a 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): n/a Approximate age of all components, date installed(if known)and source of information: SEPTIC TANK- 1982 NEW FIELD IN 2000 PER ASBULT Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10'111 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" 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: n/a 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.): SEPTIC TANK AND ALL COMPONENTS ARE STRCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 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: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R • Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a I leaching fields, number: 12.6' X 25' n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation,etc.): THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY.DID NOT EXPOSE AT TIME OF INSPECTION.SYSTEM SHOWED NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 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. Co ap- w �G�11 c C \ d'J 1] b 0 AEI �1 At 3©L c S1 �®sy �n Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30 GLEN EAGLE DR CENTERVILLE 02632 M191 P164 Owner: SCOTT LEGER Date of Inspection: 2/11/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY HAND AUGER AT 10+FEET it �= TOWN OF BARNSTABLE ' LOCH ON D WAG 4� _ VILLAGE ASSES 'S MAP & LOOT 1705P&70R, ,NAME&PHONE NO. moo• �� SEPTIC TANK CAPACITY D/Y2 0n J ' LEACHING FACILITY: (type) &AZI" (size) NO. OF BEDROOMS BUILDER 0 OWNER PERMITDATE: 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 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 t ,l i AojNw ;;7Aotj- o t a?r 3� I lql-azl No. C.�' J (p Fee s y t✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYicatfon for Mi5poear bpMem Conotruction Permit Application for a Permit to Construct( )Repair(V/)Upgrade( )Abandon( ) El Complete System L7Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor'sMap/Parcel cee cl—vlWe Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ® Other Type of Building 2 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ,�a gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /,000 P,01 i�'ksf%9ri Type of S.A.S. — Dd Q4/r14,84 Description of Soil Nature of Repairs or Alterations(Answer when applicable) / �{� >i l9/` 1�101 G�ae / 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 by t is Boar f H lth. / Signed Date Application Approved by �i Date Application Disapproved for the following reasons Permit No._24-wv Date Issued No. .. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Zipprication for -Migpoear *p!tem construction Permit Applicatiori for a Permit to Construct( )Repair Upgrade( )Abandon( ) O Complete System LJ Individual Components -Location Address or Lot No. Owner's Name,Address and Tel.,No. 3D b/eoee�le �/, /'� Assessor's Map/Parcel Joan 611 JZT ceelInstaller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. AO f/'O LO/// �7/ Q Y" Type of Building: 7 Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( 0 Other Type of Building G Cl? No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 33 !9 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /OD®�Ql �X%37`/y9 Type of S.A.S. Z `5Ofi OellUe Description of Soil /Z ✓`TX7S X Z Nature of Repairs or Alterations(Answer when applicable) 7--1,>-le 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 by this Boar f Health. Signed Date /z � d e Application Approved by - 81 Date�Z/—2 Oro Application Disapproved for the following reasons I r _ Permit No 24—Ow —f& O Date Issued C?" 24-r-o - --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CE , that the On-site�ewage Disposal System Constructed( )Repaired(✓)Upgraded( ) Abandoned( /)b at �� b ��/'Iewle el has been constructed in ccordance with the provisions of Title and the for Disposal System Construction Permit No.7-ow '509 dated " 2 -Z 00 O Installer Designer A q The issuance of this perIj stay,no. c�ed as a guarantee that the s fem ill funct'on a esign p A Date v Inspector f 41 �V --------------------------------J----(— C� �-- No.7.�"l/ S—& d ' /( _MyFee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS x1i6po5al *pgtem Construction Permit Permission is hereby granted to Construct( )Repai (� )Upg de( )Abandon( ) System located at 39 6/ei'1!f /� 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: Constructi n must be completed within three years of the date of this e it. Date: p�2 �� Approved by , i ., tV NOTICE: This Form Is To Betsed For the Repair Of Failed Sep-tic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUMON PERMIT(WITHOUT DESIGNED PLANS) I, �� � �• ��� �� 4ereby certifythat the application for disposal works construction permit sismed by me dated ���!®� concerning the property located at 30 4,o �S; GG.y1ye_ Y/1/fleets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business es associated with the dwelling. The soil is classified � / as CLASS I and the pe:cotauon rate is :ess than or equal :o : minutes per mcz i mere are no wetlands within 100 feet of he;,rouosed septic system i/ :here are no private wells within 1:0 feet of the proposed septic system w i here is no incense in flow and/or change in l.Le proposed b/ There are no_variances.requested or needed. t/ The bottom of the proposed leaching.acclity will not be located less than five feet above the mxamum adjusted groundwater table elevation. [Adjust the groundwater table.using the:rimptor method when applicable] Y/If the S.A.S. will be located with 250 feet of any vegetated wetlands. the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please.complete the following: A) Top of Ground Surface Elevation(using GIS information) ' B) G.W.Elevation 30 +the MAX High G.W. Adjustment.�. DU ERENCE BETWEEN A and B SIGNED : DATE: /04/ ]Sk=h pmposed plan of system on back]. 4F t ae flee:an I lol ao j I � I i 6`eR � � TOWN OF BARNSTABLE G6� Eil4_1?T ON �� �l�ift ���i ��' SEWAGE # VILLAGE �1'lr��l�� ASSES/SOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.,o ` 0 , 6�,5 SEPTIC TANK CAPACITY i LEACHING FACILITY: (type) (size) Xa y NO.-OF BEDROOMS BUILDER OR OWNER A4 t-%�A.- PERMITDATE: M COMPLIANCE DATE: Separation Distance Between the: V 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 i Furnished by r2oz.� A _2 a 30 loCIs7ION SEWAGE PERMIT NO. VILLAGE � ,ram u , Y/ yo I N S T A LLER'S NAME i ADDRESS BUILDER OR OWNER DATE` PERMIT ISSUED DATE COMPLIANCE ISSUED ���p_ �_. �h. �� �� �' ���� �� � ,��, -,, i // TOWN OF BARNSTA.BLE LOCATION �� 6leit SEWAGE # VILLAGE Cd19 /�tz° ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. �� SEPTIC TANK CAPACITY O 4 O LEACHING FACILITY: (type) I I (size) /,2, NO.OF BEDROOMS BUILDER OR OWNER. '. PERMITDATE: COMPLIANCE DATE: D?-.2,0P'0 0 Separation Distance Between the: j 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 t'2viv� . I A 9 3 No... .....3%.... Fimid.r............ THE COMMONWEALTH OF MASSACHUSETTS 0 BOAR® OF HEALTH , I(r ------------------ OF............... ........................ AvOratinn for Ui ivaa al Works Cnnnitrnr#uan Virmit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: .:. _......,. -.._. e-•-----•-----•--•..................•----•--------- --.......-------------•--.....------........-- at, �es,._ r LotNo.I --...... - -- ------------------------------------------o..................................................... er Address a ......................... - .. --------•-----------•-------- ••--•................•---••-•---- Installer Address d Type of Building Size Lot_. * U.$_.-Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers a yP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures ------------•----------------------------------------------------•----- -- 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. 1................minutes per inch Depth of Test Pit---.............--.. Depth to ground water..------................ LT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ===-•-•---•-•••••••--•-•-•--••-••••••••---•-••--••-•---•-••••••-•--•-••......--•-••-----••---------------------••............-•-------•--••---....---........ D escription of Soil......................................................................................................................................................-................. W UNature of Repairs or Alterations—Answer when applicable.-.............................................................................................. " •. -•--•--------------------•-------------------------------------------•-----.......----....--------------------------------------------------------•--•----------------........._----•- Agreement: T The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT 1 s�. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b�issued by t�h board of hea th. Sig --...... ................. _..._. to Application ApprovedIthe ( Z� Date r Application Disap ov lowing reasons----- .......................................................................................................... Date z - 3 PermitNo................••.................................................. Issued....................................................... Date vp No. ......�..... .... Fmi..7... .........._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F....................................... Appliration for Diipnsal Workii Tnnitrurtinn ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at L do Address or Lot No. .... C ----.. :�................ ................................................................................................. Ow Apr -"-------------•_-.•..•.-----..Address PQ Installer Address Type of Building Size feet t-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building ............... No. of ersons........_._................. Showers� yp g ------------- p ( ) — Cafeteria ( ) Otherfixtures .....------•----•--------------------------•---------..-••---•-••••............•-------- -•-••-•---•---•-•-••-•-•...........••-•......-•----•--._..... 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.................... Totd1tength.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............-........... 9 ---•--------•---------------------•----------------------------.-.----------------------------••-•-------- -....... -.------- ------ -.------------------- ...... 0 Description of Soil.............................•..................---.....---------------•--••------•-•---------......-----•---------•-•----------------------•-•-•-••----••......---•-•. U •-•----------•--------------------------------------•-•--------------------------•-------•-------.....----•---------------------...----------------•-------••----------•-------......................•- 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 I provisions of TL Li, p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by tA board of health.",',, '' Sig e'ii_ ,�. � ......--------------- ......... Application Approved B.,Ql- `=4-- ,. j = Date Application Disapptov r the following reasons:................................................................................................................ -------------------------•---• ----••-••---•••••-•••-•------••-•----•-•----------••--•-------•••-••••-•-••••--•-••-•-••---••• ............................................................. Date `.. ~ 3• Permit No.................. .................--........•--•••.•-- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................. '`:� C9rdifiratr of Toutplianrr W'IS T ERFY • hat the Individual Sewa e Disposal S-stem constructed or Repaired at....... ..'.....�._._.... .:._ _.. .. I....................K.................................................. ----------- �f f has been installed in accordance wi ' the provisions of TrLE j of The State Sanitary CX274 s d c ibed in the application for Disposal Works Construction Permit No.___! .":�.�".................... dated_.- ......�,,_/____.._...._._.__.. THE ISSUANCE 9F THIS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE THAT THE SYSTEM WIL •FUN ION SATISFACTORY. vY �'2- DATE.. -•-••---•••. •-------- Inspector...... ---------• ---'•------------------------•------••---•-----.----- THE COMMONWEALTH OF MASSACHUSETTS BOAFG OF HE L .�' S/.a" 7,. 1........................OF.. ::...:.... ....._.............................. No......................... FEES...............•..... Map t ton V rrmit SIAI Permission is reby grante '-----------•--------� mr to Consttruct or Repi " an Indio ualstem •---•- ------------•-----•-••--•••--••-•-----•.......... ......... .............. 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