Loading...
HomeMy WebLinkAbout0047 HILLSIDE DRIVE - Health 47 HILLSIDE DRIVE, CENTERVILLE A= 193 253 • �111 Ja�''�nc� llll UPC 12534 ' No.2� �� HASTINGS,MN Flynn, Judith From: Flynn,Judith Sent: Tuesday, February 18, 2020 3:28 PM To: McKean, Thomas Subject: Emailing:47 hillside drive, Centerville .pdf Attachments: 47 hillside drive, Centerville .pdf Your message is ready to be sent with the following file or link attachments: 47 hillside drive, Centerville .pdf Note:To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. 2016 21:51 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 47 Hillside Drive Property Address Roy Cobb Owner Owners Name information is required for every Centerville MA 02632 page. CitylTown 3-10-16 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ' ❑ drawing attached separately r I�-i anti 9AifA G A � —y=,13` � S�FPS e-- el 360 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / s �1 SYSTEM INFORMATION (continued) l Property Address: % � A �/S,; e I/f'/v-!J COH /0/� Owner: /.<,Ij 'k Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ;3 13 \I xiv j�«.✓�r 2 25411 3 31 ' 26 ' L1 33 36 „ (revised 04/25/97) Page 9 of 10 a 16 2016 21:49 Jim The Inspector Man 5085349919 page 1 �■ Commonwealth of Massachusetts . Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yt 47 Hillside Drive v Property Address Roy Cobb s Owner owner's Name information is required for every Centerville MA 02632 3-10-16 page. Citylrown State Zip Code Date of lnspe 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. General Information „��„Ilflfllr►��►,, filling out forms S/# OFMq on the computer, si' use onlythe tab �� c key to move our 1. Inspector, Z; •,SG y y y JAMES :m cursor-do not James D.Sears r, use the return Name of Inspector V SE IRS r" key.' Capewide Enterprises, LLC �* • *� VIC] Company Name Obi(F 5°I N SpSG```````�� 153 Commercial Street . ����unuunu,na�``� Company Address Mashpee MA 02649 Citwown State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails F ❑ Needs Further Evaluation by the Local Approving Authority 3-10-16 ,pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. [sins•3113 Tide 5 offic at Inspection Form:Subsurface Sewage Disposal System-,Page 1 of 17' �o �VS Mar 16 2016 21:49 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form a - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page, Cityrr'own State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist_ Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal.Tank D Box and pit. B) System Conditionally Passes: ❑ One or more system components as'described in the"Conditional Pass" section.need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank Is metal and over 20 years old`or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I 15ins•3113 Title 5 Official Inspection Forth:subsurface Sewage Disposal Sfstem•Page 2 or 17 Mar 16 2016 21:49 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments: 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page.. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health). ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND.(Explain below): ❑ obstruction is removed ❑ Y ❑. N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 151ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 17 Mar 16 2016 21:49 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS Is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of.a private water. supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis,performed at a DEP certified laboratory, for 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_ 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component dine 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 somplalill is less than 6" below invert or available volume is less than '/Z day flow 417T l5ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page of 17 Mar 16 2016 21:49 Jim The Impector Man 5085349919 page 5 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 160 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] 0 ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either''yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone I I of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 - Title 5 OHic at Irspec6on Form:Subsurface Sewage Disposal System•Page 5 of 17 Mar 16 2016 21:49 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page. Cityrrown state Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located.on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of,scum? ❑ ® 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. Ell ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)] D. System Information Residential Flow Conditions, Number of bedrooms (design): NA Number of bedrooms(actual)* 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Mar 16 2016 21:49 Jim The Inspector Man 5085349919 page 7 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is Centerville MA 02632 3-10-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal Tank D Box and pit 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspectioh ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 2014-28,000Gals Water meter readings, if available(last 2 years usage(gpd)): 2015-27,600 Gal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seatslpersonslsq.ft., etc.): Grease trap present? ❑ Yes ❑ No In waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins-3i13 TBIe 6 Official Inspection Form:Subsurface.Sewage Disposal System Page 7 of 17 Mar 16 2016 21:50 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If.yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•X13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 8 of 17 Mar 16 2016 21:50 Jim The Inspector Man 5085349919 page 9 <LN\ Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is Centerville MA 02632 3-10-16 required for every Page. city/Town State Zip Code Date of•Inspection D. System Information (cont) Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or-suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipein is 4" PVC SCH 40 Septic Tank(locate on site plan): 14" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years of Compliance? attach a co of certificate Yes ❑ No Is age confirmed b a Certificate ) ❑ 9 Yp ( pY Dimensions. 1000 Gal.Precast H-10 Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Mar 16 2016 21:50 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form ? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is -Centerville MA 02632 3-10-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(oont.) Distance from top of sludge to bottom of outlet tee or baffle 29" lit 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 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tank and covers at 14" below grade. Inlet tee-outlet baffle. No sign of leakage or over loading. 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 I5ins-3113 Title 5 OKciel Inspection Form:Suosutaca Sewage Disposal System-Page 10 of 17 Mar 16 2016 21:50 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is Centerville MA 02632 3-10-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Mar 16 2016 21:50 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page. Clty[rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 , Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box under large stone steps. Camera out to Box. Box looks ok. Did not open Box. 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. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t t5ins•3113 Title 6 Dfridal Inspection Form:Subsurrace Sewage Disposal System-Page 12 of 17 Mar 16 2016 21:50 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leachingis a 1000 Gal.Precast pit. Pit at 30" below grade w/cover at 18": 30"water in pit. No sign of over loading or solid carry over. Note: Pit under stone wall.Pit cover can be dug up and opened. : Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17. Mar 16 2016 21:50 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name information is Centerville . MA 02632 3-10-16 required for every page, City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): L l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Mar 16 2016 21:51 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 47 Hillside Drive Property Address Roy Cobb Owner. Owner's Name information is required for every Centerville MA 02632 3-10-16 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells Within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ,I9-1 = 012, GARAGE , c L` y_ -13 ,. STf P s 15in s 3/13 Title 5 Official Inspection Forth.Suhsurfece Sewage Disposal System•Pa ge 15 of 17 Mar 16 2016 21:51 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °• 47 Hillside Drive Property Address Roy Cobb Owner Owner's Name Information is required for every Centerville MA 02632 3-10-16 page, . City(Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na Estimated depth to high ground water: 30' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet,of SAS) ❑ Checked with local Board'of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Rear of lot and area drops off 30'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3113 Title 5 Official Inspection Form:Subsurface Sawa ge Disposal System•Page 16 of 17 Mar 16 2016 21:51 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 47 Hillside Drive Property Address Roy Cobb _ Owner Owner's Name information is required for every Centerville MA 02632 3-10-16 page. CityfTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•3;'13 Title 5 Official Ins ection Form:Subsurface Sewage Disposal System•P 17 of 17 P P 8 Y � i, COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI 1=� DEPARTMENT OF ENVIRONMENTAL PROTE 'ON RECE1IVEO ONE WINTER STREET. BOSTON. NIA 02108 617-292.5500 pto„ 2 1998 '�'� NOV " TOWN OF BARNSTABLE ` HEALTH DEFT f A,/ WILLIAM F.WELD � TRUDY Qrbl Governo: y5'ecret�an ARGEO PAUL CELLUCCI �PAVID B RUHS g Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner I G J PART A �s3 CERTIFICATION Property Address: 11 7 /yi��S�o+/ Pei v 4-4C!H t4i�G�/l�f Address of Owner: Date of Inspection: /p--:7— 9'8 (If different) Name of Inspector: I am a DEP{appf oved sy�}e ^sp for ursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J H /71�ir.0 04v/e 4P Mailing Address: /S-y UZ, T, Telephone Number: ra -! 2,2 ys-4S— 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 ofinspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: l000 Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority s Inspector's Signature: Date: �� Z 7- 9� 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: 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. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon. completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y,,N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank,-whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, 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 04/25/97) Page 1 of 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep 0 Printed on ReryGed Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) _ kl Property Addreisl: y7 N6//S Owner:' Air,- gl,��/i��-„f Date of Inspection: 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(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: 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: 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. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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 facilii Rand the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used i determine-'distance (approximation.not valid). 3) OTHER ' (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 'J CERTIFICATION (continued) Property Address: Owner: Date of Inspection: �o- tla-9� D) SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.3:03. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 cfmed SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesswol. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the 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 waver 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 suppy well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: 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 significarc threat to public health and safety and the environment because one or more of the following conditions exist: 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 fl of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treament program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: /(j rk Date of Inspection: la- 17-98 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No y _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. I The facility or dwelling was inspected for signs of sewage back-up. v _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for siggns of breakout. _ All system components, @*6a hng the Soil Absorption System, have been located on the site. _ The 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: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 0 } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �—SYSTEM INFORMATION Property Address: //y7 r•/,, ple Plv�✓,e Clti/rYlii��a Owner: Date of Inspection: la"27- 98 FLOW CONDITIONS RESIDENTIAL: Design flow: 3'W g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:• Garbage grinder (yes or no):_AIS Laundry connected to system (yes or no): ' Seasonal use (yes or no):__A/p �8 : y6 Go0 97 s Ad 6 oda /q6— �soC,n Water meter readings, if ay table (last two (2) year usage (gpd): Sump Pump (yes or no): X�'P Last dale of occupancy: hCLc�1t.40 COMMERCI.AUINDUSTRIAL: Type of establishment: Design flow: >;allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: Ives or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available Last,date of occupancv: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: .S .5 rj/^ /1/!dam/• L4 r+ System pumped as part of inspection: (yes or no) Ff If yes, volume pumped: /OHO gallo�s Reason for pumping 0-vvo)e e 101, 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 9 >Qo" Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ss SYSTEM INFORMATION (continued) Property Address: y7 �`'�,/s1c�� Qriv� C1s,�1r lii���� Owner: /L j,,A wi Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: 30�� Material of construction: _cast iron 40 PV _other (explain) Distance from private water supply well or suction hr•e Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: /3 Material of constructions concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: .$ /)(- yS� Sludge depth: ? ' Distance from top of sludge to bottom of outlet tee or baffle: AW' Scum thickness: /1 AV. ' �'' RAO" oit' Distance from top of scum to top of outlet tee or baffle: d Distance from bottom of scum to bottom of outlet tee or baffle: g�� How dimensions were determined: Pk I. F sic/s 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.) Tati/4 wGs nuw�a i�o f s �7�. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: .Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) (ravimad 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 1,6v' s Date of Inspection: /O--Z-7 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacim,: gallons Design flow: gallons/da� Alarm level: Alarm in working order_ Yes; _ No Date of previous pumping: 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: t� Comments: (note if level and distribution is equal, evidence of olids carryover, eviden a of leakage into or out of box, etc.) av>y PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Nib/4" Pel ✓-0 C'0AT4 e Owner: k,Y r A Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: . leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil,.signs gf,hvdraulic failure, level o ponding, condition of vegetation, etc. 1.0 c t Cot,, !r 'e octi /v h✓ w�i/ r „ � 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:_ (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.) (ravimad 04/25/97) Page a of 10 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �1 SYSTEM INFORMATION (continued) Property Address: �7 � SYe b7 t� -' f-1 v-ll COH 4 /��o Owner: �.</,ek W1 Il r�rh S Date of Inspection: /o-,� 7-- 59 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) W xty 41 3 31 " 26 ' y " 33 36 (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Property Address: 417 12rr✓v C"-1 Owner: k,vk W //i 4 r s Date of Inspection: 70 Depth to Groundwater K Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record 1,,/ Observation of Site (Abutting property, observation hole, basement sump etc.) V Determine it from local conditions -/Check with local Board of health Check FEMA Maps Check pumping records f/ Check local excavators, installers 1/Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) GdNtH� q�vr"'al rv«-lee e/0 is 3S,o ' Y , L70�/dht Q./ f. e�L� �Ji,� �S 3t�, r Qt7vv� �YUcav,pf k4►.ft0 :R(. (revised 04/25/97) Page 10 of 10 rde .APPLICATION FOR. PERCOLATION TEST AND OBSERVATION PITS �(LOCATION LAKEVIEW _ 3 2S�orl.S NO VILLAGE CENTERVILLE DATE APPLICANT R. ARTHUR WILLIAMS, INC. FEE ADDRESS # 2 OAK STREET. CENTERVILLE TELEPHONE NO. 428-5717 (Non-refundable) ENGINEER BAXTER & NYE _TELEPHONE NO._428-9131 DATE SCHEDULED_JANUARY 8, 1986 0930 : (Applicant' s -,signature) .- - • • • • • • o • o • m e e • o • o o e e o e e o o • • • e e o • o o o • • • • • • o • • • o • • • o • • • • 0 0 0 0 • • • • • e • o • o • • • o o • o • • • • • • SOIL LOG _ rt SUB-DIVISION NAME LAKEVIEW DATE JANUARY 8. 1986 TIME g- '— EXPANSION AREA: YES X NO . _.,.._ 1 14 ENGINEER TOWN WATER_X_PRIVATE WELL i� BOARD OF HEALTH . . ALFRED FUi.1.FR EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in-.proximity to test holes ) - 1 Coo NOTES : 0 2S' � l F L CC1l�__ Tt 0� - �o' PERCOLATION RATE: t7tti&J- TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2 2 4 4 _ 6 6 7 7 8 8 - 9 9 10 10 11 l( 11 12 1 ' 12 13 �o N ZD 13 14 t_l S E l_�-� 1 1, 14 ' 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT �( 9....••-•- -�� Yule ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH cw�4. ..............oF.�! .0 ................................. Apptiration for Bigpooal Works Tomitrurtiurt Vernfit Applicatiori is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: - A .._...... ------ ------- - (� L•oc;ati�oj-A�dyyes� f /� /� ` Lot.Nyo. / cam..-----DS...IL_�: --sJ`yc7-�C� — Jrrl�(y P F�l1/1 ...... Owner Address ..................................................... ..&///..�%............ Installer j Address d Type of Building Size Lot_ ) )®..Sq. feet V Dwelling—No. of Bedrooms___..._________________________________Expansion Attic ( Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fix es -----------------------•--•.... . W Design Flow•.......................................gallons per person per day. Total daily flow........... ...................gallons. WSeptic Tank—Liquid capacity_Iallons Length---------------- Width................ Diameter_--_--__--_.____ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....____.__I........ Diameter....... ....... DepNi below inlet.............. Total leaching area. f=)..sq. ft. Other Distribution box Dosin tank ( p� ` Q z Percolation Test Results Performed by. sX`t -1� -1�`�--..__.....•.. Date.A: „,.l Test Pit No. 1-.Z9�:----minutes per inch Depth of Test Pit....11............ Depth to ground water_A[1°T_ � LT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----•-•-- - -------- ---------••--••------•----------------------......_......... Description of Soil----D-P I 1 tM. �?�i��1 .....-�......-- x V -----------------•--•-------------------------•--------------•-------------•-------•---•-------------------------------------------------------------------------------••---••---•---------------- W -------------------------------------- ------------------•-----•------------•--••---------------•------•-------------•----••---•----------- ............................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------------------------------•----------------------.........._.--•-••----•--•••-----------------------•-•-•••-•-----------------.........------------..............---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certi ' ate ofQomplia s been issu d by the board of health. Signed --- --- - - — -- 41 -"I .. ApplicationApproved By --- -- - -- - ---------- -- - --- ----- _ ....---- --. ......... .............................. ........................ Dace Application Disapproved for the following reaso --- ---------------------- ----------------------------------------------- - ----=-----........--------------------.-.....---------------------.....------.-:--------------....--------------------- .............. Dace Permit No. ---7,62 Issued -----�--- --�---C --- ----------------------- Dare . / �" C) No. FEic Z ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Works Tnnitrnrtiun ramit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at: B --- ..l....` ................................d f 1 Locatipy�-A`�dy�es. or Lot No --- . ....._. (, ...'�.. -••3° -t-:- ` ?:.'' --------------------------•--......-•----. . ------......................................-- Owner Address W a ........ .'... ......................... � . Installer Addres s s . . �� Type of Building ti Size Lot ' _=w-,� _ __Sq. feet U Dwelling—No. of Bedrooms...... .................................Expansion Attic W,0> Garbage Grinder `4 Other—T e of BuildingNo. ofpersons-........................... Showers — Cafeteria 04 Other fixtures --•------------••---•--•-•••------ W Design Flow•._.._..._. � ........................gallons per person per day. Total daily flow----------- ...................gallons. �sv. WSeptic Tank—Liquid capacity..i�-k llons Length................ Width................ Diameter--.__-__.___-._- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------1--------- Diameter.......E:?....... Depth below inlet_.<�_.°............. Total leaching area2rCA ..sq. ft. Z Other Distribution box (�1I� Dosin ank ( t Percolation Test Results Performed by.__ 3 C>._....._... Date`�:_°.`.... � Test Pit No. I_.: -_-minutes per inch Depth of Test Pit....1.1............ Depth to ground water_►'_I Bt� fZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ----- -------------------•----•-------- ---------- - 0 Description of Soil......0.--� � Q v Va.._ _ �a 1- '-�' 1 k A I',—=��-- f:'�`�^-r� �'� --._..... --••--r V .............•.......................................................................................................................................................................................... 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 Environmental Code—The undersigned further agrees not to place the system in-operation until a Certi ' ate of pliance has been issued by the board of health. a_ 1v- yv Signed ,- ... .............. .. -- ----------- Application Approved BY J �/. . _1----- ... ............. y ...............;-.-.-. Dale Application Disapproved for the following reaso . ......................... ...... ............................. ............................................ ...... .. .. ............ . . ...... ------------ - ------ -------------- ------------------------ Da[e Permit No. ------------------------ Issued aQ` Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ C�er#t�ictt#e IIf C�om�littxcce THI_,LS.TO R IFY, the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ----------\J-C, :..-.. 1 L ..............................................................---------------------- ---- ------- *----------------------------------------------------.--------- j Installer _ at 4,...� - .i.. .: �..ti. -- -(., --------------------- - - ---- -- --- has been installed in accordance with the provisions of TITLE 51 he t Environmental Code s MTHAT n the application for Disposal Works Construction Permit No. .---- �.... . ...... dated,-- -- -.. ..��THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARA TEE E SYSTEM WILL FU CTION TISFACTORY. DATE...4F1. �-............................................. ,l Inspect 1 w 9 THE COMMONWEALTH OF MASSACHUSETTS f. BOARD OF HEALTH 3 �., ...€ No. FEE. ...... ............ aisvrrsa w6par _ ion rrniit Permission is hereby granted .- L/L�? --------------------------------------------•------•--•-•--•-••--••-•---•--- to Construct (�s') or Repair, ( ) an Indwldual_Sewage,,D> posal System at No.......- c ` . .....+. ••.=' I- x ; ?��f . ............... �`3= �s.. •l __ Street _?-7 � . as shown on the application for Disposal Works Construction Permit No _ __.._/. - ated..... .. .. ........... .......... ... ..............................----•--- -*�__ - ------------- ----•-•----.---- VBoard of Health DATE................................................................................ / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS I )),y/t ,SOWN OF 13ARNSTABLE LOCATION 4.ct 67 /�5, e ,2�:� _.__ SEWAGE VILLAGE ritier v G( ASSESSOR'S MAP & LOT 3 � INSTALLER'S NAME & PHONE NO. JoAe� fI= hQA0 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �;'�" (size) lo��� `" NO. OF BEDROOMS .3 PRIVATE WELL OR PUBLIC WATER u0/ic BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No o 9\' w j a , �S 1 Cs 1.L SSE,l ,110 C-zaR3�.brE G-TR►ta�t� ���.as • "p,o,I L`C r maw ; •_l l D x3 r 33a�w S t_PnC.1 ar.s�C 33a a1z-og g95C,PrD U5� �oara G��.Lo�: S�Fn�)o.►�►c i � . l s Yo s��F tT-�- u s E .�oaz? C��l..►,a u tin- `�-_.•---� . 14/t-rN 1': CR115{}GL7 ST©f ly tN OF M'q5 AREA ls0 SF J ,j�� ° PETER SULLIVAN t�o-�ZpM UXTETZ No. 29733 v; /�R.M/. +. SaaF 1� tl�.240 ^, 'off o Ca4ac ° ° �' a Ili(° 605E OL, I O SO CPU cCISTco` t G. �' C S/ON.t E �16 s f7 I e k - LO� S• "D1�tt,`C F'►.ow 330 Er'PD �"� k' �'t F.t(-o1,A.TIa1J-RIcTC . ►.'TZOY IN 'ZK%".OZLr05 -- '~rcr ••� ` � TE 5 r7 �'. -7 T, =' SCo7 T�F�c�CEf4AJ B.aF}9s �' C�4 Toe of Fti117 So$ :a IODZ? 1N\/ Fv ANY L F R4 uK i -P 1 8 C RTI FI E-D PLa-t' PL A111 s�utr I, 6 I. EL 'i2.� �,o�ATtaN� Cr=ti�Le�Y1�-�-� ►-�1�5�; =40 t�A►�: tz •Iq�8� 4; 9 PLAK RI=F�RrNGG 'S 9V./ac "o��8Cr� �a�� Z'7 511 I C.F-Z T'1IF F Y -T'I-1 fst`r TI-E E ov,u S7A�t0 ail 5 H L7W}� I�E6 l S 1�Rt Q ? I�tZ�z�l�l cz�h�t�?4—`tS �1 t t'N 4� SIDE I-1�.1� �-�\!t E�.►Erlcl25 `ANC 5�T'>3�K �iEGxlt�t✓t,4�tyT5. �FT�-lE �-s i t��1 t,>`�.� �h� .: tS v� vAc _�4T��1_IAA,t�IT: ��. -v 2 ;1_2>CA�i� arc/IT►411J TH E.'F'I-OrJZML. ,)1.1 Tx t5 R.Rti l5 NUT 1,n5� R oNHN I STRu ME:NT 5URYCY MID THE oFF5ET5 5HoOWN 5Ht)uL-D TgoT 13E USEQ TLD E5TaT3)_)5 N Lz;;-f' t,I N E S. r Z Z ij O ` zc zap F t t t�`t ' s '�r4 �S T r Y Y'� SI^t- � k,yr l ( � � f t _ _ • �• �;.1 <,�- f� -,-yam i.� � A � ,�.srlk S 2 ( J p v + �. 1 � V 1. E y � - . -. 84 sz aq ,fir gG 1 Z8 Z,005F `a Cec 4 S! C7�O ��i; LPIT k •''�tN PATER' i r 8O 1 ULLIVAN No:29133 o 79. Of RICHARD '� a sC.r4 L i 1T" t"� Nc sic ORS !_ o-r 1 1 L L_IS I-DE : �f 9EC/STER�� .. h0`[®E�� 1/i L. La. �'�( A, 2Tti y �G�t t_t.1�M S V i LL I A4��