Loading...
HomeMy WebLinkAbout0108 GLENEAGLE DRIVE - Health 108 GLEN EAGLE DRIVE, CENTERVILL A= 191 157 i i Sl/ll____/� Jaa�cvctFoco� UPC 12534 o- No. 2-153LOR HASTINGS, MN c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 108 Glen Eagle Dr. V Property Address Carl Berger Owner Owner's Name information is required for every Centerville Ma. 02632 3-3-21 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path r� Company Address South Yarmouth Ma. 02664 City/Town State Zip Code r�mn 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes p�u��uuln�iuU,,� �SZH OF M,gSS111, 2. ❑ Conditionally Passes MICHAEL�••.N 3. ❑ Needs Further Evaluation by the Local Approving Authority SO SEARS "-. No.SI14430 cl' 4. ❑ Fails S 3-3-21 Inspector's Sig ure 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information.which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): F t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, t safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 18 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is required for every Centerville Ma. 02632 3-3-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the.Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 C Commonwealth of Massachusetts - Title 5 Official Inspection Form k yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is required for every Centerville Ma. 02632 3-3-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- El10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the.system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form += yI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every State Zip Code Date of Inspection page. City/Town C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. El ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e / 108 Glen Eagle Dr. u Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2019- 19000 gal2020- 32000 gal Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c V � 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is required for every Centerville Ma. 02632 3-3-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: July 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r; 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is ill Centerve required for every Ma. 02632 3-3-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 4-11-06 #06-153 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 18 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �.. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Glen Eagle Dr. u— Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 8„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gal H 10 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal H10 1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" 0 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank H10 with in and out tees in place both covers 8" below grade in stone side yard t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 cam, Commonwealth of Massachusetts IP Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Glen Eagle Dr. v Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form Not for Voluntary Assessments c � 108 Glen Eagle Dr. u— Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 H2O with 2 outlet pipes, cover at 12" below grade t5insp.doc•rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 ,<Z'\ Commonwealth of Massachusetts �n Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2 Drywells wells are dry and clean with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r. ..........h 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): b t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e / 108 Glen Eagle Dr. V Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Shed a to r . o `ruvi^�• 3 A OF'41,q j W.6 Q � - �� ��. MICHAEL .u� o. SEARS �- �. 3 S No.S114430 °Fp T If ° p SO t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form I1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 108 Glen Eagle Dr. Property Address Carl Berger Owner Owner's Name information is Centerville Ma. 02632 3-3-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ®, Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 132 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: 2-24-05 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: No groundwater per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Glen Eagle Dr. v Property Address Carl Berger Owner Owner's Name information is ill Centerve required for every Ma. 02632 3-3-21 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked . ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included d e • �� �o�-t®� m�' SsfS . It 5� I °L 0 6rbcoi - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TO OF//BARNSTABLE p� LOCATION SEWAGE# o -VILLAGE (flf� ,, ASSESSOR'S MAP&LOT Jv INSTALLER'S NAME&PHONE NO. !„ll) ��. 5 SEPTIC TANK CAPACITY - LEACHING FACILITY: (type). (size) .!NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: gl l K 180 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) f �6 Feet Furnished by (� f I _ 1^► s c7 �� , �3 , �� � 5 � °� � � D ._ - �, . , r v LOCATION SEWAGE PERMIT NO. VILLAGE ��•�/7�reY/LLB eAl4 UZG?3 INS TA LLE�R'S NAME i ADDRESS el 57 0 U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ._ I a At' } TOWN OF BARNSTABLE Cs LOCATION / 5' �r�en �� ` 2c SEWAGE # 062 - /5'3 VILLAG ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 0—"e w t &Q r, ;. `z!a C/o 0 ll SEPTIC TANK CAPACITY EX 1st l 0 o V. 1 t O LEACHING FACILITY: (type) ..Soo C 6.tC (size) ) 01 k NO.OF BEDROOMS 3 BUILDER OR OWNER t� PERMTTDATE' LO _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility va CQ !Z Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) i Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) d Feet Furnished by q3 33 (v A� p a-) _ ay 19.-, A No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for TDigozal *p5tem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(,-<Abandon( ) ❑ Complete System'LJ Individual Components Location Address or Lot No. I e i 6A*-,&410 praw, Owner's Name,Address,and Tel.No. Assessor's Map/parcel tell r 1 /D Y G L t Installer's Name,Address,and Tel.No. `clt fn� Designer's Name,Address and Tel.No.,f1-ky 4 vC4-a:A-&-AJ 7 �P� yc.l �e yyy�l 5r3 l(os 6 . iW0Td v fA An 3(e Type of Building: Dwelling No.of Bedrooms Lot Size 6>/ 0 3 sq.ft. Garbage Grinder Other Type of Building 511yk Tl vv l( No.of Persons -2— Showers( ) Cafeteria( ) Other Fixtures Design Flow(main.required) 3,30 gpd Design flow provided 3 - d gpd Plan Date Number of sheets / Revision Date Title l C T G 1F1 C Size of Septic Tank /coo Type of S.A.S. tzj 54o W- 1Qw_4 c4oftayi Description of Soil Nature of Repairs or Alterations(Answer when applicable) T`O�V � G Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. YZ&— Date Issued f .�� � �06No. �/. � �.�� � as --• �. -� Fee / f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zp Yication for Bi5po5ar *p5tem Cow9truction Permit Application for a Permit to Construct( Repair O Upgrade(Abandon O ❑ Complete System 1elndividual Components Location Address or Lot No, +Q 006Bri t.jta P f,Ls<— Owner's Name,Address,and Tel.No. Assessor's Map/Parcel G'(1 /t J 1 Installer's Name,Address,and Tel.No. L— .ln A f"�� Designer's Name,Address and Tel.No. �� �/ie'o+K � P-J. 13 z,K �c-7 -� �z7 3-3` Type of Building: , �z Dwelling No.of Bedrooms 3 Lot Size 1S/ O 117 sq.ft. Garbage Grinder ( ) Other Type of Building S/h/�C f7�++�+�r No.of Persons Z.. Showers( ) Cafeteria( ) Other Fixtures + �. �22 0 -3 3 ! .�" o Design Flow(main.required) 7,3 gpd Design flow provided gpd F Plan Date 1 Number of sheets / Revision Date Title Of 6161"C-1,tle r Size of Septic Tank coo Type of S.A.S. ZJ )o0 5 A�. L A"#w,,, F_ r ' Description of Soil c,, p n 1 bAm Nature of Repairs or Alterations(Answer when applicable) !J Y� L pS G Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordaricewith the provisions of Title 5 of the Environmental Code and not to place the system in operation untiI a Certificate of Compliance has been issued by this Board o_f Health. I Signed' L,—Date Application Approved by /// / / ) Date Application Disapproved by: v Date v for the following reasons Permit No. A­�- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance i THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded /�rr � A -C ✓� t s LL Abandoned( )b/y C� a ,ke at /0 l (of C�h Gr,,1�C ��^� 6" t 1(/ C has--beeenn constructed in accordance ) ----__.,with the provisions of Title 5 and the for Disposal System Construction Permit No. 0°�'"(P 5/ dated 17 Designer �Installer ' #bedrooms Approved design'flow gpd The issuance of this perm t sh n t be construed as a guarantee that the system will nction as esi e Date Inspector ------/--� I�7 ---------------y------ Fee -----= THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS tgogaY i§p!9tetn Con.5tructtonermtt Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( Abandon ( ) System located at 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. must Provided: Construct io. be c mpleted within three years of the date of this pe"it. Date �I t/ Approved by � '%IIPS r � - 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM • 4 ) 5-ut Y ,hereby certify that the engineered plan signed by me dated q l.. ( concerning the property located at a t b � C k (� l'e eets. all of the following criteria: • This failed system is connected to a residential dwelling only.:There.are.no commercial or business.uses.associated with the.dwelling. • The.soil is.classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests at the site without a health agent present. There is no.increase in flow and/or change in use proposed • There are no variances requested or needed. • The.bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) (9 b 6 B) G.W. Elevation 30 +adjustment for high G.W. DIFFERENCE B EN A and B aL,,4— SIGNED : Z' , DATE: 5 O NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. , 2,15.Z q:\.Sepdc\percexemp.doc {L TOWN OF BARNSTABLE LOCATION /vim 1`r Q 11' R SEWAGE # D!o - /S 3 VELLAGE C Y11 Pry t.l 1 , ASSESSOR'S MAP & LOT 1 /S INSTALLER'S NAME&PHONE NO. (14W-e w t &9 5,n ya Y0 a k SEPTIC TANK CAPACITY f--<t i t 1000 I A t O LEACHING FACILITY: (type) Q SOO 6\ary%6cf(size) NO.-OF BEDROOMS 3 BUILDER OR OWNER r 1 TERMITDATE: 0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility wo /Z Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) , r Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I �3 33,E pc� 38 .1 33 asp � Q 0 irljil 'i I�11 TROY WILLIAMS RECEIVED 4art SEPTIC INSPECTIONS J U N 1 2 1996 Certified by MA Department of Environmental Protection It&!ti]l VE W(58)`760-1819 40 Old Bass River Road South Dennis,MA 02660 L H/ Commonweafth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WHHam F.Weld Trudy Coxe aovwnor _80—(„y Argeo Paul Cellucal DaM IL Struhs LL Gowemor Cornmisslorw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION J 0 /� / rU Property Address: / � V u,. /- �l c /',.. ��.�� �'� Address of Owner. L,r ul� Date of Inspection: 6/�-/�j G (If different) /vim L rK r✓+ L a. Name of Inspecto--7-1, W; 1/r6-K,y Company Name,Address find Telephone Number. C«t-��;If, /Lt u S« v-2c3 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _Vse Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Impectot's Signature: S „ •,^L� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: VL I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BI SYSTEM CONDITIONALLY PASSES:////i One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. U"not determined",explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or enfiltration,or tank failure,is imminent. The system will pass inspection if the existing septic tank is replaced with a Conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /6 % Owner. Date of Inspection: 415 /5 / B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(@) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:/JM- Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. 9) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address Owner. ^/ Date of Inspection:/YbQ D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination fs identified below. The Board of Health should be contacted to failure. determine what will be necessary to correct the — Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool. _. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool. — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. — Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped — Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. — Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: . The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: — 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 Il of a public water supply well) The owner or operator of any such system&hall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Ads 1 6 N F4 f Owner. /11/0 o c L Date of Inspection: Check if the following have been done: �[Pumping information was requested of the owner,occupant, and Board of Health. 0. Siti None of the system components have been pumped for at least two weeks and the system has been receiving SS. during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow JZThe site was inspected for signs of breakout. Z�Lll system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. , The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. JZThe facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. MOO L k Date of Inspection: / /S/ 7 RESIDENTIAL: (o FLOW CONDITIONS Design flow: 3 oglina Number of bedrooms:_9 Number of current residents: 0 Garbage grinder(yes or ao):_6�O Lary connected to system(yes or no):-G S Seasonal use(yes or no):_A/O Water meter readings, if available: Last date of occupancy: COMMERCIAL/INDUSTRiAi• N(i9 Type of establishment: Design flow:_ gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: / L aZ w'4-1..5 .s✓�br System pumped as part of inspection: (yes or no)Ao If yes,volume pumped: gallons Reason for pumping: 'I'PPEQF SYSTEM 1_ 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: I. 5 ki- A / /ply/ff D Sewage odors detected when arriving at the site: (yes or no) A(O (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /O K G/c h 3/G Owner. Date of Inspection: SEPTIC TANK:y (locate on site plan) Depth below grade:,, Material of construction:✓concrete_metal_FRP—other(explain) ` Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: /IWI Distance from top of scum to top of outlet tee or baffle:/Vo S "^ Distance from bottom of scum to bottom of outlet tee or baffle: /�/o Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.)—y— L�')e-✓ 7os v ti A ,-"A � 4 ti� ;� W o r /.� , � s �r Cj 4.v A/ GREASE TRAP:_A//,q (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—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: Comments: (recommendation for pumping, condition of inlet and outlet tees or banes, depth of liquid level in relation to outlet invert,structural integrity' evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: a Y l e i � S /.c Owner. ^ o v Date of Inspection: / V TIGHT OR HOLDING TANK:/V//1 (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP_other(explain) Dimensions: Capacity: canons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (n if level and distribution is equal, evidence of evidenceO solids carryover, evidence of leakage into or out of box, etc.) ^ / PUMP CHAMBER/V O (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Owner. ,A/b o 41 Date of Inspeotion: G /� G SOIL ABSORPTION SYSTEM(&4,$)._L/' (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: leaching pits, number: leaching chambers,number._ leaching galleries, number. leaching trenches, number,length• leaching fields, number,dimensions: overflow cesspool, number: Comments (note condition of it signs of hydraulic failure, level of ponding, condition of vegetation,etc.) ��a S. LJ/"t W Lr� l�0"c-S t(i+ Su. i.J K S CESSPOOLS: (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_.XA///9 (locate on site plan) Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION (continued) Property Address: �6 D�/ G le-/1 G�� OWnef' 1116 d 6k Date of Inspection; SKETCH OF SEWAGE DISPOSAL SYSTEM: lndude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' _73sc /7 /6vo 66 r4�sc.� a 's � DEPTH TO GROUNDWATER Depth to groundwater: feet adjusted high groundwater lewd method of determination or approximation: S. 4 /Q /%It Ke2s I f Lt.0�,, �, /J`/'L s eH t / Ll 7 --- hn G 9 N .� 3 . ..... F Fss.. ......_ THE COMMONWEALTH,OF MASSACHUSETTS BOAR® OF HEALTH ............................ ..............OF....................................... Appliration for DiopooFal Works Tanarurttun rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at L tion- dd ss or Lot No. VD a .._l..7.. ..[..:.._....SE�1. .n .�y.. .:5........... .......1t�-_r......V....4_! ...!....�` ......__..__..._.............._•---- Installer Address Type of Building Size Lot_/Ur e:.0...Sq. feet Dwelling—No. of Bedrooms............ ...........................Expansion ttic ( ) Garbage Grinder (Nib aOther—Type of Building _. 6. --_---_-- No. of persons........................... Showers — Cafeteria ( ) d Other fixtur -------------- ---- Design Flow.............. ........._ ..gallons per person per day. Total daily flow........... __.----.--_-_.gallons. Septic Tank—Liquid'capacit�.gallons Length................ Width................ Diameter................ Depth......_......__. Disposal Trench—No..................... Width. ....... Total Length.._.......7.._......Total leaching area....................sq. ft. Seepage Pit No.......J........... Diameter......?......... Depth below inlet................. Total leaching area� �....sq. ft. Z Other Distribution box (I ) Dosing nk ( ) '" Percolation Test Results Performed by-----K.°...... . Date....T= . _... a Test Pit No. 1 -minutes per inch Depth of Test Pit.......V.......... Depth to ground water.... ................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a Descri Description of Soil . � � ...... _ � // .. e � Glf�J'�?.. � c.� ---•----••-------•-•-••-•-•-•-...•-•-••---..._...-•-----•-•---- w x -••-------------------------------------•-•-•--•-•-...---••--•---••---•--------------------------•-----------------•--•----------------•------------•••-----•----•---••••-----•---------••............-- 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 TITL 11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en i ed bye the oard of h �tth. -7 / � Signed ............................ 1 ''•..•.- Date Application Approved By........ •---•....................•-- 7.-' Date Application Disapproved for the following reasons--------...................................................................................................... --.........-••-•-•-•-•••••••••-•-••••...••-•-------••----•--••••••---•--•--•--•--•.._...-•••-----....--•-------------•-•--•--•---•--•---------•-•----------•---•-------•-•-----•-----••---•---•--•----- Date a PermitNo......................................................... Issued_...... ....... -- .................. Date 9 N . IP FEB_ -....................... THE COMMONWEALTH OF MASSACHUSETTS- BOARD OF HEALTH i ....... ..... ----------.............OF....................................... ................................. Appliration for Bhipoii al Works Tonotrnrtinn thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at L lion- dd ss or Lot No. a �... . c°"ne S fly ........i/ `gym(/ ` � Installer Address Type of Building Size Lot_/16�a ....Sq. feet U Dwelling—No. of Bedrooms......... ✓_______________ Expansion �ttic ( ) Garbage Grinder N(D ----_ Other—Type of Building ...Odd b __........ No. of persons____________•____•_--_______ Showers � — Cafeteria ( ) a' Other fixtur -------------------- - - -- W Design Flow.............. ...........................gallons per person per day. Total daily flow........... gall ons. WSeptic Tank—Liquid capacitAW.O.gallons Length---------------- Width................ Diameter•_--_-__.___-___ Depth................ x Disposal Trench—No..................... Width _f_.__._......... Total Length......__...__ Total leaching area___•._•._••••-______sq. ft. ___ Seepage Pit No........�._.....-... Diameter______ _ _ Depth below inlet._..`!...._.._.._.. Total leaching area +: ....sq. ft. Z Other Distribution box (� ) Dosing ank aPercolation Test Results Performed by.....K.�...... Lqi + ! ` ...................... Date_. .7 a Test Pit No. 1 6C .;l7ninutes per inch Depth of Test Pit...... ......... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Descri 'on of Soili U 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en i R ed b_ythe oa�hth.Signed... ........... •• . .........................................._....••-• •...." Date . Application Approved By-•.._.1,effollowing 1 r� --------------------------------- .::-7':_�l_'1 ....... Date Application Disapproved for t reasons:...................... --------------------------------•-------------........................................ .:...••••...:.............••••-••_..--•-.........•••••----•=•--•-••-••-••••---••--•--_............-•••••.•••-•••••-••-••••••-••-••-•--•••-••••--•••----------••-•••-•......--•-•--•-•-••. lg Date Permit No......................................................... Issued " .. Date ._..._...---•--•••---•-•••--- f THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH 0•-t,,i.. . OF........... .. ..r ...................................................... �rrtifirtttr laf ��ant�gi�anrr THIS IS T010ERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) f W�t-. ' ....... --•----•----------•---------------•---- p by---T __ _-• --------•�•-__•--•• ................•-•- Installer , at :: , .� �� has e'en installed in accordance with the provisions of T 5 of Tlfe State Sanitary Code as described in the application for Disposal Works Construction Permit No.- 0 ._S_ /p--_I------------- dated-----7=.,;?/_--..I................. ---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CTION SATISFACC))TORY. DATE-•.................... ..�:•-_Z.S-. .................. Inspector_._ --------e --- ------- --••-----_.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD' OF HEALTH .......� ................OF.......t&gam ............................................................ ...... No. ..... �9 FEE....., .... Disposal Vork.. U=strnrtion Val it Permissionis hereby granted•.... > ,�••..-• ----------------------------------------------------------------------------------------------------------------•-•----••---- to Construct ( " Repa ( ) an Indi6du 1 rage Dispo Sy tem at No.)... Str ` as shown on the application for Disposal Works Construction Perm i No_____ ___ ______ _ Dat d.._.__ .., .1.-..Ct`:•J........ - �� /1,� -•=------------------------ DATE Board of Healt1;P( ' y,�d FORM 1255 HOBBS'-& WARREN, INC.,,PUBLISHERS - - -� SECTION SEWAGE -SEPTIC TANK - - "D" BOX - - LEACH 4 TOP OF FDN /vJ.Z3 .. S(MSL)x "2"OF�/aT0 1/z" G3, _ � WASHED STONE :Q- q IN- OUT•• I N- U T - !`'Q../f�isV. cJ "�' r / ......^._____ •-. ��ryry 760, O I N TANK ELEV. ELEV. ELEV. ELEV. v � ____v p ELEV. ELEV. 5/i / ZI, OF 3/4"-11/2,. 2-45—=— ty} / s 4) WASHED STONE /// TEST HOLE LOG ,! j� !f csc- TEST BYI .3'.4XJK �� Ae s 7/ZB/96 WITNESS _-� BEDROOM HOUSE ` �(I TEST'DATE DESIGN 41r,0 '17• T.H. # 1 T.H. # 2 ELEV. 6Z•O ELEV. NO z I �, 41,5.s PERC RATE 3 MIN/IN. 23 DISPOSER FLOW RATE ,3,30(GAL./DAY ) 0 - /or�p cc /. °• Cc��ov /��. SEPTIC TANK .�3� (�'�= V S fr�Tzoo ,.5as REQ'D SEPTIC TANK SIZE 1600 54.0_ " LEACH FACILITY \j SIDE WALL // (c'00) = 339 G/D. 4 - BOTTOM 7T�fhr, Z ( . 1 = _ Z _ G/D. _ TOTAL = 4 � ^ USE: LEACHING A © WATER ENCOUNTERED r NOTES: (UNLESS OTHERWISE NOTED) , a\tit� � 1.DATUM (MSL)+TAKEN FROM .... . -----------__QUADRANGLE MAP •� /� f 1 2.MUNICIPAL WATER --_ .•_..1...�--------------•---•-----AVAILABLE t % �� $. PIPE PITCH 'i/4 ,PER FOOT eF V✓ JA1�ES v> 4 4.DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO r� 44 J JAVMI � / �� . ' !• ( d?_ H —`� --Q--DISTANCE AS CERTIFIED i 5. MIN.GROUND COVER OVER ALI.SEWAGE FACILITIES: (1) FT. G. PIPE JOINTS SHALL BE MADE WATER TIGHT j�_� EC�4 +) tQ v.I e f �3�i1FJM�N U r 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. u 103£, ( I HEREBY CERTIFY THAT THE BUILDING SITE PLAN k STATE ENVIRONMENTAL CODE TITLE 5 SHOWN ON THIS PLAN IS LOCATED ON THEJ Locus: Lv 7- GROUND AS SHOWN HEREON&THAT IT �j 7 �l ;' �•.__ t CONFORM TO THE ZONING BY LAWS OF THE �f'Li= GSA ��. LJ IG IiWGC ', i, ------- -- �- TOWN OF REG.PROFESSIONAL ENGINEER WHEN CONSTRUCTED. DATE REF: 31 V 15? 7< L07- L�G / i down Cape englneerInz PREPARED FOR: ��r�p // - 1 I CIVIL ENGINEERS 106 ,�+�?� of ft/, A 4L Ine LAND SURVEYORS ------------ BOARD OF HEALTH , REG. LAND SURVEYOR /Ir ZO 7 � � CONTOURS (EXISTING) -- SCALE (PROPOSED}^0-0-0-0— APPROVED —DATE- MA Yarmouth&Orleans,�MA DATE �1; u Y SECTION - SEWAGE � T - SEPTIC TANK - - "D" BOX - - LEACH TOP OF FDN 1 J 4�r G3,�j ry ---- I - •`- (MSL)x —..Z�.OF�'aTO 4z„ tll ------- ' ' WASHED STONE , —I 1� ny, , �, Wry .•r.A'� \ / �� I 1 S ,l �7 OUT IN - OUT IN %-�i I��•:�.� >r,s �.`-i� � '� - -- ---� 1p/0 �Q 7 j SEPTIC TANK ELEV. /j \ ELEV. ELEV. ��-� ..,�/.. ELEV. '. ELEV. ELEV. �• �` 1� j WASHED STONERvc ii� ,✓ — /j, / /,' / I� TEST HOLE LOG ' _ , M 77 fc�ccc5� �I TEST BY °�$.c}n11� _/�'✓ �C � E'C_: ac`''; TEST;OATE 7/Zua �F3C� W _ EDR HV DESIGN --B OOM OUSE T.H. # 1 T.H. # 2 � E _ ` 4 LEV. ELEV. t / ,f. LOFJoII r�StJ+',S / — DISPOSER PERC RATE FLOW RATE _330 (GAL./DAY ) .� J I I ��{{ �I �—--—c^ --- y1c� SEPTIC TANK 3G� (�`-1= , -- - -- SE�f+c o�z� isf to ,f �eoc��/7, REO'D SEPTIC TANK SIZE V y 5"4,O_ _ LEACH FACILITY _ ,,_ 1 SIDE WALL — . ( r -- ( W'JI _ � rG/D. BOTTOM _ -LY` ��M — ( '-=) _ _ '~:. . G/D. I L �1 } TOTAL = �—b0 J ' ° ' _.y j% t USE: __ ^±�r� LEACHING rC�saC � No WATER ENCOUNTERED -- `--- NOTES: (UNLESS OTHERWISE NOTED) / �'1 1. DATUM (MSL) +TAKEN FROM -__�yq—"'.5. ..-----._._QUADRANGLE MAP �..g .: { t, 2. MUNICIPAL WATER__r_____-__1...�._____.___________------AVAILABLE 3. PIPE PITCH: ba"PER FOOT 4. DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO - 44 e 5. MIN. GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. — y-''r r^� 1 + ( {' 3 ' 'a,� " DISTANCE AS CERTIFIED 6. PIPE JOINTS SHALL BE MADE WATER TIGHT RCJ�"diUt^•Pi I:. - 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM. OF MASS. "C i j. \ R111>� STATE ENVIRONMENTAL CODE TITLE 5 1 df \ J^r r- I 1 HEREBY CERTIFY THAT THE BUILDING SITE PLAN SHOWN ON THIS PLAN IS LOCATED ON THE rStf,,��� GROUND AS SHOWN HEREON & THAT IT LOCUS. IV T CONFORM TO THE ZONING BY LAWS OF THE ,CGc�" '1 .�S TOWN OF /. .' , /!/A= REG. PROFESSIONAL ENGINEER WHEN CONSTRUCTED. DATE / . /�� �..�� REF: � 7/ C.^7- down cape engineering PREPARED FOR: `��' Z4�; — CIVIL ENGINEERS /p� _�y �ltJG, y�Gj�/�1 , LAND SURVEYORS ——————— --——— BOARD OF HEALTH REG. LAND SURVEYOR CONTOURS (EXISTING)------------- SCALE� (PROPOSED)—O—O—O—O— APPROVED DATE _ Mp IfYarmouth & Orleans,MA , r p DATE _. # r