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Home My WebLink About0020 HALYARD WAY - Health 20 Halyard Way Centerville.. .P Slll J� � UPC 12534 No.2153LOR w HASTINGS,MN ...�lr.;:.�..w.w...,u�—..�-�z:...w-_::......a.: � .:.�, may. .. _..... __ _ _ �...x-. _..,--.._.._.._.........,........: l Commonwealth of Massachusetts - - .� Title 5 Official Inspection Form Not-for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information M-194 P-086 Important:When filling out forms 1. Property Information: on the computer, use only the tab 20 HALYARD WAY CENTERVILLE \ key to move your Property Address cursor-do not FRANCIS MCINTOSH use the return key. Owner's Name 61 FULLER BROOK AVE Owners Address NEEDHAM MA 02492 City/Town State - Zip Code I Date of Inspection: 2-13-08Date 2. Inspector: JAMES D. SEARS #S-1623 Name of Inspector BLUEWATER Company Name 4 350 MAIN ST _ Company Address WEST YARMOUTH MA' 02673 Cityrrown State r 'Zip Code` 508-775-2800 Telephone Number C_s_ - B. Certification I certify that I have personally inspected the sewage disposal system at this address and that-the information reported below is true, accurate and complete as of the time of the inspe tion. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-13-08 pectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or,DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System.. Page 1 of 16 ' Commonwealth of Massachusetts - Title 5 Official Inspection Form _.._ . Not for Voluntary.Assessments Subsurface Sewage Disposal System Form ****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. B. Certification (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection 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: B) System Conditionally Passes: N/A ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of.Health, will pass. Answer yes, no or not determined(Y, N, ND) in the❑ for the following.statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate. of Compliance indicating that the tank is less than 20 years old is available. ND Explain- 20 Halyard Wy T5.doc.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System /� Page 2 of 16 Commonwealth of Massachusetts --- - Title 5 Official Inspection Foram .. ........ Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) .20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code, FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): NIA ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are'replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: N/A ❑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)(0)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 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts y� Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh B. Certification (cont.) .20 HALYARD WAY Property Address CENTERVILLE MA 02632 Citylrown State Zip Code FRANCIS MCINTOSH. 2-13-08 Owners Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): N/A 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other.- 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Ins ection Form:Subsurface Sewage Disposal System- Page 4 of 16 Commonwealth of Massachusetts -- . Title 5 Official Inspection Form - ... .._... Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State _ Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection D)System Failure.Criteria Applicable to All Systems: N/A You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage.into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due-to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet.invert due to an overloaded or clogged SAS or cesspool ElLiquid depth in pit is less than 6" below invert or available volume is less than Y2 day flow . ❑ 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface-water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of_a public well. ❑ p 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 ofammonia 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.] ❑ z The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. Yes No ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 20 Halyard Wy T5.doc.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection. Form ..... Not for Voluntary Assessments / Subsurface Sewage Disposal System Form B. Certification (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection 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. N/A For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200.feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question.in.Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 20 Halyard Wy T5.doc.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- ��/"� Page 6 of 16 i Commonwealth of Massachusetts ---- -- Title 5 Official Inspection Form ... . ...._ k' Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owners Name Date of Inspection Check if the following have been done.You must indicate"yes" or"no" as to each of the following: YES NO ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ x❑ 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? arge.volumes of water been introduced to the system recently or as part of El Have l 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? Z ❑ Was the site inspected for signs of break out? x❑ ❑ Were all system components;okcluding 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? • ❑ 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: ❑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(5)] 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System e Page 7 of 16 Commonwealth of Massachusetts - - - - Title 5 Official. Inspection Form Not for Voluntary Assessments ` .,.. ,�=` Subsurface Sewage Disposal System Form D. System Information 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): Unknown . Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A Number of current residents: 0 Does residence have a garbage grinder? ❑Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑Yes 0 No Laundry system inspected? ❑Yes 0 No Seasonal use? Nyes ❑ No 06-164.39gpd/ Water meter readings, if available(last 2 years usage(gpd)): 07-230.13gpd Sump pump? ❑Yes 0 No Last date of occupancy: SEASONAL Date Commercial/Industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑Yes ❑ No Industrial waste holding tank present? ❑Yes ❑ -No Non-sanitary waste discharged to the Title 5 system? ❑Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 20 Halyard Wy T5.doc.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts --- -- � Title 5 Official Inspection Form .._.. . Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection General Information Pumping Records: Source of information: N/A PER B.O.H. Was system pumped as part of the inspection? []Yes x❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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: SYSTEM AROUND 1985 D-BOX REPLACED 10-1-02 Were sewage odors detected when arriving at the site? ❑Yes 0 No 20 Halyard Wy T5.doc.doc•03/2006 Title 5 official I ection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts p Title 5 Official Inspection Form i� Not for Voluntary Assessments Subsurface Sewage Disposal System Form .yvV D. System Information (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection Building Sewer(locate on site plan): 46" Depth below grade: feet Material of construction: ❑ cast iron N 40 PVC ❑ other(explain): Distance.from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): PVC SCH 40 Septic Tank(locate on site plan):X 24" Depth below grade: feet Material of construction: x❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a.copy of ❑Yes ❑ No certificate) Dimensions: 1000 GAL PRECAST 1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" o„ Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" ' How were dimensions determined? SLUDGE JUDGE 20 Halyard Wy T5.doc.doc-03/200'6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- /7 Page 10 of 16 v/4 'e' Commonwealth of Massachusetts -- - Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK AT WORKING LEVEL, IN&OUTLET BAFFELS, OUTLET COVER AT 1', NO SIGN OF LEAKING OR OVER LOADING Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 ... ........ ......... Commonwealth of Massachusetts ' Title 5 Official Inspection Form Not for Voluntary Assessments 4 k Subsurface Sewage Disposal System Form D. System Information (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection. Tight or Holding Tank(cont.) N/A Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments.(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? El Yes ❑ No Distribution Box(if present must be opened) (locate on site plan):X Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-BOX IS 16"X16"-10" BELOW GRADE, BOX IS CLEAN &SOLID ONE LINE OUT, NO SIGN OF OVER LOADING OR SOLID CARRY OVER Pump Chamber(locate on site plan): N/A Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts ---- -- � Title 5 Official Inspection Form .... . ......... Not for Voluntary Assessments 0 Subsurface Sewage Disposal System Form D. System Information (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): X If SAS not located, explain why: Type: p leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: . ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of.hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): LEACHING IS ONE 1000 GAL PRECAST PIT, PIT&COVER AT 26" BELOW GRADE, 2"WATER, NO SIGN OF OVER LOADING OR SOLID CARRY OVER. 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System �� Page 13 of 16 s Commonwealth of Massachusetts ......... .. ...... Title 5 Official Inspection Form Not for Voluntary Assessments ............ /,.= Subsurface Sewage Disposal System Form D. System Information (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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 13Yes 11 No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 Citylrown State Zip Code FRANCIS MCINTOSH 2-13=08 Owners Name Date of Inspection 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. 30 y9 qt o �4 ., �µ.uvv.uuc vo��uw Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts - Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 20 HALYARD WAY Property Address CENTERVILLE MA 02632 City/Town State Zip Code FRANCIS MCINTOSH 2-13-08 Owner's Name Date of Inspection Site Exam: Slope YES Surface water NONE Check cellar YES WALK OUT Shallow wells NONE Estimated depth to no ground water: 20'+ Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑x Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: USGS WELL SDW253 ZONE A LEVEL 48.5 ADJ 1.8 You must describe how you established the high ground water elevation: AREA HIGH END OF STREET DROPS OFF. TOOK GRADE. 20 Halyard Wy T5.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 16 of 16 y O V I `OF I w I I as o d F a: � TOWN OF BARNSTABLE LOCAT30N �/�L/ /�A°� �//1 SEWAGE # r '.TILLAGE ASSESSOR'S MAP & LOT ,/ INSTALLER'S NAME&PHONE NO. �� SEPTIC TANK CAPACITY �'L ��,AC £ 2) LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER O .OWNE ^ �ti Sy PERMITDATE: COMPLIANCE DATE: �D 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 ,- �' £9�' '_ `-� 30 . �y o \\ 0 \\\4�c/ t No. Zoo?--�� Fee J 6 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migozar *pztem Construction Vermit Application for a Permit to Construct( )Repair( l [Jpgrade( )Abandon( ) ❑Complete System 14�dividual Components Location Address or Lot No. 9 U ��L�� N/�I Owner's Name,Address and Tel.No. Al CES o%7 c- Assessor's Map/Parcel '�,1 0 8� p //4)_,YA1P3 jc�_A y C £ Installer's N e,Address,and Tel.No. SO P,7 F) S�Fin- Designer's Name,Address and Tel.No. � " Cg^,C-O Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) C r DI /19 oho< 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 is d by this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. ZUV 2- -t Date Issued �d 0�- LI i Fee S THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I/t/ Yes ` f PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 0[ppYicat o-tf for -Migpo.!6a'U item Con�truction Permit M r' Application for a Permit to Construct Repair Abandon( ' ), ❑Complete System [A In''dividual Components II Location Addressor Lot No.j a N.G�,�.3 W#4 91 Owner's Name;Address,and Tel.No. 4' j Assessor's Map/Parcel 101.1 01L' O g� `+ wd4 Y14"f A Y C r— ; ; f Installer's Name,Address,and Tel.No. riv Designer's Name,Address and Tel.No. id Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow /gallons. Plan Date \ Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 104P r 0,,4 4 C C h + �I r 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- i 1—cate of Compliance has been is d by this Board of Health.� — , Signed2ts.= "'� +.•r- Date Application Approved by Date ' Application Disapproved for the following reasons (r. i Permit No. ZUU Z ' t{ Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS P,,r BARNSTABLE, MASSACHUSETTS Certificate of Compliance f THIS IS TO CERTIFFY,that the On- �On-site Sewage Disposal System Constructed( )Repaired( )fJpgraded( ) 4 Abandoned( f y / T 46 fo/,�1IAO �_a �_f(P AV/0,/4,1 110 at Q X ez 4 /1 k c r,,,9' has been constructe4 i5 accordance ' with the provisions of Title 5 and the for Disposal System Construction Permit No. Zw2 - '/,y dated IL Installer Designer The issuaVc o tqis permit shall not be construed as a guarantee that the systeqZ function as d- ' n d. Date I �z Inspector I---------------------------------------- No. 2 UD-Z Fee THE COMMONWEALTH OF MASSACHUSETTS - . PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSET' Migogal *pgtem Construction Permit Permission is hereby granted to Cof struct )Repair(�L'�Tpgrade( )Abandon( ) System located at cxa- 0 �•f 4 ' '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:Constru fio must be completed within three years of the date of this p t. Date: it �Z Approved by r i TOWN OF BARNSTABLE G C 17 SEWAGE # LOCATION o .L Cry ASSESSOR'S MAP & LOT l y j VILLAGE— 7 7 Is,'; a— INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY j LEACHING.FACILITY: (type) (size) A NO. OF BEDROOMS j BUILDER O OWNE f y PERMIT DATA: l " COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) exist Edge of Wetland and LeachingFacility (If any Feet within 300 feet of leaching facility) Furnished by g 30 s �y 0 91 COMMONWEALTH OF MASSACHUSETTS ID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � W d DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET 6 WEST YARMOUTH,MA � 508-775-2800 t-zlk TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 194 PAR 086 Property Address: 20 HALYARD WAY RECEIVED CENTERVILLE,MA 02632 Owner's Name: MCINTOSH,FRANCES Owner's Address: 20 HALYARD WAY OCT 1 5 2002 CENTERVILLE,MA 02632 Date of Inspection OCTOBER 1,2002 TOWry OF E-��'�!STAE3LE HEALTH DEPT Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F 'ls Inspector's Signature: Date: f6, The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ i have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): Broken pipe(s)are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" Broken pipe(s)are replaced Obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 . a Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 C. Further Evaluation is Required by the Board of Health: N/A _ 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the Condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with information on the Proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of Distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 t e Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: I 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): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 119,000/2001 108,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,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: 1999 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: AGE OF SYSTEM 1985.NEW DISTRIBUTION BOX OCTOBER 1,2002. Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 BUILDING SEWER(locate on site plan): ./ Depth below grade: Materials of construction: ./ Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): Depth below grade: 24" Material of construction: ./ concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND 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.): MAIN TANK AT WORKING LEVEL.OUTLET COVER 24"BELOW GRADE.OUTLET BAFFLE.NO SIGN OF OVERLOADING. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: %f (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.,): DISTRIBUTION BOX IS NEW OCTOBER 1,2002. BOX IS 16"X16".ONE LINE IN,ONE LINE OUT.COVER 10"BELOW GRADE. PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 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: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER 26"BELOW GRADE.20"WATER IN PIT.NO HIGHER STAIN LINE.WALLS CLEAN.NO SIGN OF OVERLOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 ♦ f t Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal s stem including ties to at least two permanent reference landmarks or g P Y g benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. R FAQ b 0 Title 5 Inspection Form 6/15/2000 10 Page I I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 HALYARD WAY CENTERVILLE,MA 02632 Owner: MCINTOSH,FRANCES Date of Inspection: OCTOBER 1,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 48+ feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: V Observation 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: USGS WELL DATA USGS WELL SDW 252 48' AREA HIGH g 07 7 � pii Title 5 Inspection Form 6/15/2000 11 E � J L0 iiON 5 £ E PERMIT NO. VILLAGE INSSA LLER`S NAME A ADDRESS C BUILDER OR DWNElt DA ; E PERMIT ISSUES DA7 E COMPLIANCE ISSUED r l� u,� THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH OF... ................................. Appliration for Uhipoii al lgorkii Tous#ruriiun Errant Application is hereby made for a Permit to Construct ( 9,<or Repair ( ) an Individual Sewage Disposal System ..... �..... .... • .••_..� ........... ......•••• A ....................................... catio ress. t :lam_. .---........ . �.. � -to... 12 .............. w dd ss FW' ... ................ ........ Installer Address Type of Building Size Lot/ .......Sq. f t V Dwelling—No. of Bedrooms.........�...........................Expansion Attic Garbage Grinder ((� a'4 Other—T e of Building No. of persons....................•....... Showers YP g ------•-•-----------•--•---- P ( ) — Cafeteria ( ) Otherfxtures ............... .•------------•--------•-------------....------------------------------------------ ¢¢- --•---. ' WW Design Flow...........lza______________________gallons per person per day. Total daily flow------- ........................gallons. ;l C� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ ' i 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 to ) hq Percolation Test Results Performed by.......... . ... .......... ...5�.... . ............ Date.../r�_�.�_'"�4V....... 1.4 ,.� Test Pit No. 1................minutes per inch Depth of Test Pit................... Depth to ground water........................ Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ................._ ....• ... -•- •----•------------------•---•---..--.--------•------------------------------------------ Description of Soil '_s -. :.% .... -•-------------------•--------------------------............---•-•. 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 TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation Atil a Ce ifiqate of Compliance has been issued by the board �fl�,eaSigned•--•-- �-----lam._- ............ Date PPlication Approved BY•--•--•---••• -•-•-• ----- =_`....G--.--- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•-------------------------•----- ................•-•-•••-•-•--••••-•-•-••--••••••.....----•-•-•....----••-••---•---•--•--•-••---•••••-••-•---•-•••------•-•••------------•-•---•-•-•----------••--•--......-----•--•• \ Date PermitNo........ r - -� --------- Issued....................................................... Date_ --------- --� No y. ------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , Appliration for lliiposal Workii Tonitrurtion Famit Application is hereby made for a Permit to Construct (4-1'-or Repair ( ) an Individual Sewage Disposal System at: r ........L Z , -,/ a/ � 2ocation�rAddress 411 i° or Lot No Owrrer" Address.- --------------------------------- ,/�1�r f..�_ /`i � . --------.. ...........-•--- .. � Installer Address U Type of Building Size Lot�_-`q�Jf1� Sq. feet Dwelling—No. of Bedrooms......_.: _.........•....................Expansion Attic elf J Garbage Grinder �16) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------•-----------...------.......-•------------------------------------ ,... ... W Design Flow.......... �0.......................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;,( ) r aPercolation Test Results Performed by....... '� �{ :. ........ Date.. ....................................V �_l Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit............._...... Depth to ground water........................ a -------•-------------------------- -----•----- y ----•-•----------------------•----•---------- Description of Soil...............-----.... J =} '= - U ...................................... l�% ( iP.n .,!i;._r_!:._ ®••R!•'"!�' __ �.f2;i�-."YL; .._..._......._................_-.....-._.._--.-----. 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 TITA LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. _ Signed_ -- /` ....... - D ate Application Approved BY - 6� ........................................ Date Application Disapproved for the following reasons:--•------------•---------------------------------------•------•-------------------------•----••--•............-- ----------------•--............--•-•---•---•--••....--•-•••••-----••••-••-------•----------------.........--•---------•••-•-•----•-.....•-•--•-------••-•--------•----•--•-•-••-••-•----•--•----------•- Date E s Permit No.......... .._.. = 7 - —` - ----•-- Issued------------------ -----^• Date -------•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (Irrtifiratr of Tontplianrr TIJYS IS TO CERTIFr,, That the Individual Sewage Disposal System constructed (✓) or Repaired ( ) JI-et Installer at_-.......................... s� fi' Ccr,/........' .•/ems .1. .!/!�i has been installed in accord ace with the provisions of TITLE 5 of The State Sanitary Code s described in the application for Disposal Works Construction Permit No.__... ........ dated------ ?.f'5----------------- THiNSSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE �Q-.'. � ........ Inspector--••---- . � 1,�1,� .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �f �j�j� 1 -�..f �ft✓ OF:W /Rr,r ac <'✓_:%r(/ --- 'j...................... JU No........................• FEES... :.......... Maposal Works Twonitrurtion antit permissionq,hereby granted----•--••••--•••------•..... .............•'--•---•-••-----•---•-•---•-•----•--........................................................... to Construct;-( or Repair (, ) an Individual. Sevt age Disposal System F at No..:- ../_ ... /�c...... v i iJ-� �--' ,� Street as shown on the application for�'Disposal Works Co struction Permit NZ-__;,.*? a.. Dated.._ v�......................... h Board of Health DATE............... FORM 1255 A. M. SULKIN, INC.. BOSTON it/O GA2.B.4GE Ni a SEF�T/G' r i I 5`9�G.P.v. � :-� %- � R��✓� -� �. 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