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HomeMy WebLinkAbout0095 HOLLY HILL ROAD - Health 95 Holly Hill Road Centerville A= 188 -096 0 Commonwealth of Massachusetts �u Title 5 Official Inspection Form COPY Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -C 95 Holly MIII Road Property Address Michael_Walker Owner Owner's Name---------- --- ---- - --- - -- .�t — information is required for every Centerville ✓ MA 02632 May 4, 2017 page. City/Town State Zip Code Date of Inspection J1 Uri 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return ------------------- ---- --— Name of Inspector key. Ready Rooter Excavating _ _ — rffi Company Name P.O. Box 89 --------- -- ---------------- Company Address Forestdale _ MA 02644 City/Town State Zip Code 508-888-6055 S112843 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 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �- -- -: --- Ma rZ8, 2017 - --- ---- Inspector'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. t5ins•3/13 title 5 Offirial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 117 �O �N _ y t Commonwealth of Massachusetts .- --ka Title 5 Official Inspection Form _ >> Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Holly Hill Road__ Property Address Michael Walker Owner Owner's Narne information is Centerville MA 02632 Ma 4, 2017 required for every ----------- ------- - --- -- - --- -- y -- ----- page. City/Town State Zip Code Date of Inspection B. Certification (cont.)~ Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: D-box and outlet lines replaced just prior to inspection. COC attached) 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. / y i * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tankis/less than 20 years old is available. ❑ Y ❑ N ❑ NO (Explain below): t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form el Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _. 95 How Hill Road _ Property Address Michael Walker Owner Owner's Name information is Centerville MA 02632 Ma 4, 2017 required for every � page. City/Town state Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms 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 ealth): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed / ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveledfor replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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 t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 95 Holly_Hill Road Property Address Michael Walker Owner Owner's Name information is required for every Centerville MA 02632 _M_a-4, 2017 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. r ❑ 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. i 3. Other: j f r D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow 15ins•303 1 itle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 95_H_o_lly Hill Road _ Property Address --------- ----- --_ _-_- Michael Walker Owner Owner's Name information is Centerville MA 02632 Ma 4, 2017 required for every —y -- -- -- page. City/Town State Zip Code Date of Inspection B. Certification (cant.) 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 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or`ono" 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 withinj200 feet of a tributary to a surface drinking water supply r ❑ ❑ 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page,5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Iz) FI _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 95 Holly Hill Road Property Address Michael Walker_ Owner Owner's Name information is Centerville MA 02632 May 4, 2017 required for every -__ - ------ page. City/Town 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. ® ❑ 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): 4 - Number of bedrooms (actual): 4-- -- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a` 95 Holly Hill Road _ Property Address Michael Walker Owner Owner's Name information is a Centerville _MA 02632 M 4, 2017 required for every _— —y page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 -- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No GPD Water meter readings, if available (last 2 years usage (gpd)): 2015= 85 2016- 5 GPD Detail: Sump pump? ❑ Yes ® No Current_ Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: - --- r Design flow (based on 310 CMR 15.203): ;' Gallons per day(gpd) i Basis of design flow (seats/persons/sq.�Jetc.): - 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: — L 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 95 Holly Hill Road _ -c-� — ----.. --- - -- Property Address Michael Walker _ Owner Owner's Name information is Centerville _ MA 02632 Ma 4, 2017 required for every -- --�_ 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: Ready Rooter records: Pumped Feb. 2017_ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Holly Hill Road Property Address Michael Walker Owner Owner's Name information is Centerville _MA 02632 _Ma 4, 2017 required for every — _Y 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: Sy_ em installed 1973 Ori final ermit on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.8 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): -- Distance from private water supply well or suction line: n/a _ feet Comments (on*condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: — - feet Material of construction: ® 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 certificate) ❑ Yes ❑ No Dimensions: 9' x 5' x 5.5' 1250�c allons Sludge depth: <1" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments e V 95 Holly Hill Road _ Property Address Michael Walker Owner Owner's Name information is Centerville MA 02632 May 4, 2017 required for every — —� — page. City/Town —_ State Zip Code _ Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" <1„ Scum thickness -- - - Distance from top of scum to top of outlet tee or baffle 6 — - Distance from bottom of scum to bottom of outlet tee or baffle 14 _ How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet concrete baffle and outlet PVC tee in place. Outlet has Zabel 1800 effluent filter in place. Recommend cleaning filter every year to prevent colgging and back up. Liquid level at outlet invert. Risers brink covers within 6" of grade. _ Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: - Scum thickness f` — 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 t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,J 95 Holl Hill Road ' ------------- ------ Property Address Michael Walker _ Owner Owner's Name information is Centerville MA 02632 May 4, 2017 required for every _ _Y page. CityrTown 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 i 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts SwF Title 5 Official Inspection Form — = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Holly Hill Road Property Address _Michael Walker Owner Owner's Name information is required for every Centerville MA 02632 May 4, 2017 page. Cityrrown 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 011 -- 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.): One inlet, two outlet. Installed just prior to inspection. H-20 DB-3 with riser within 6" of grade. Speed levelers in place. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No i` Alarms in working order: / El 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: t5ins•3/13 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts c Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _,.. 95 Holly Hill Road Property Address --------- ---------__.-_-._.------- ---- ---------------------- Michael Walker Owner Owner's Name information is Centerville MA 02632 Ma 4, 2017 required for every — page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6' x 6' w/ stone. ❑ 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.): Leach pit#1: empty with dry base at time of inspection. High water staining 1' up from base. Leach pit #2: 6" of liquid at time of inspection. High staining 4' below invert. No sign of past hydraulic failure in either pit. #1 pit has riser that brings cover within 6"of grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): n Number and configuration Depth -top of liquid to inlet invert it - --- Depth of solids layer - - Depth of scum layer ----- - Dimensions of cesspool / — - 1 1 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 Commonwealth of Massachusetts 1R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Holly Hill Road_ . t nr 7�6 ye Property Address _Michael Walker Owner Owner's Name information is Centerville MA 02632 May 4, 2017 required for every — — page. City/Town 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): j Materials of construction: -- Dimensions / Depth of solids �' -- ---- — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ' r� ,ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 14 of 17 ' c Commonwealth of Massachusetts Title 5 Official Inspection Form ' - cl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 HollyHill Road _., -_.------------ Property Address __---- ----- —-- --- _Michael Walker _ Owner Owner's Name information is Centerville MA 02632 May 4 2017 required for every _ _ page. City/Town 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 I I 1 r 0 rY t t� 3 -7 / � I C-) t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 = = .e p iR Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Holly Hill Road Property Address Michael Walker Owner Owner's Name information is Centerville MA 02632 Ma 4 2017 required for every — _ —___—.— _ -- .—.— ��__--- — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >2feet 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: 1973 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: �I ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole in 1973 found no ground water at 11.5' Base of leach pits 8.5' below grade. Hand auger in empty pit 2' below base showed no ground water after 30 minutes. Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Holly Hill Road Property Address Michael Walker _ Owner Owners Name information is Centerville MA 02632 May 4, 2017 required for every — _ Y page. City/Town 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 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS ` e ftificate of Compfiance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V� Upgraded( ) Abandoned( )by at . ', has been constructed in accordance ) 1 Q with the provisions of Ale 5 and the for Disposal System Construction Permit Ne��'/Jddated Installer u��14 Designer #bedrooms Approved design flow gpd The issuance ofith s permit shall not be construed as a guarantee that the system will fun as designed. , ^ Date _ Inspector ,Y(C t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I • �^''� No. � v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS YeS 01pplifation for Mispo8al *pstrm Construction Permit Application for a Permit to Construct( ) Repair(,,/Upgrade( ) Abandon( ) ❑Complete System 2 Individual Components Location Address or Lot No.�!S l �',\i \JZ-- Owner's Name,Address,and Tel.No.-17 1?7-0C)-� Assessor's Map/Parcel ` 0� Installer's Name,Address,and Tel.No.67C37-SY1Z'6� Designer's Name,Address,and Tel.No. 7 pe 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(min.required) gpd Design flow provided gpd 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) y�z•.r�J BCD 11;(�, - ��Gbz �`,�n` y�� vcsy-e-- v` lam- k Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Sign Date 1� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. t' Date Issued No. . _ Fee r THE CiOMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplicatlon for bisposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(V)"Upgrade( ) Abandon( ) ❑Complete System Pindividual Components Location Address or Lot No. S ����l �',\l �/� Owner's Name,Address,and Tel.No.-17((-9 27-CO-r_�T Assessor'sMap/Parcel ` Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. R� Z­t,k-� 005<—r z5FKcr.4 C, C_ -ZED, \ 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(min.required) gpd Design flow provided gpd 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) `7 S , Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in— L accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal h. Sign r" Date 17 Application Approved by Date LA Application Disapproved by Date for the following reasons Permit No. Date Issued Li r -------------------------------------------------------------------------------------------- -------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(VI) Upgraded Abandoned( )by at Kq� . has been constructed in accordance y)l I j with the provisions of Tile 5 and the for Disposal System Construction Permit No�/7'1�0'�dated `�' // !� Installer �c� c�� , �C,e�l r Y�-au r,G Designer #bedrooms Approved design flow gpd 1/ �� • The issuance of this permit shall not be construed as a guarantee that the system wi func t n•as designed. Date 9`1 Inspector ------------------------ --------------- - -- - ------------------------------ No. d J / � � Fee--��— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS misposal �6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at �S ' AC_)(�,A and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction`must6bb c I p/leted within three years of the date of this pe it. Date `-y /� ( Approved by . -- ��Y�-7_Y Commonwealth of Massachusetts �i�-. rn Title 5 Official Inspection Form Wi-1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Prope.-ry Ad r ss _ Owner Owner's N e y� (� information is --�,0I;P-yi Ile /'/� od 62� 7` -0 51 '�} required for Cam= every oage. City/Town State Zip Code Date of ins ec ic-; --- Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms to the computer, use I. Inspector: only the tab key " to move your cursor-do not Name of Inspector use the return ,/� key. �,11 VJ O 7 _ Company Nampo Company Add ss Pa .,S, 0�6 City/Town mown 2 /! State // Q ZIP Code Teleph e Number License Number i B. Certification I certify that I have personally inspected the sewage disposal system at this a �: ss anc4*.at t information reported below is true, accurate and complete as of the time of the;—,- p8cti0P,The�rspec cn was performed based on my training and experience in the proper function an ainteng ce of on. site sewage disposal systems. I am a DEP approved system inspector pursuant to Sectionv15.34,0 of Title 5 (310 C R 15.000). The system: c n Passes ❑ Conditionally Passes ❑ F-ils [] Needs Further Evaluation by the Local Approving Authority 02 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving ,!Ft`;o;i;y ! o of Health or DEP)within 30 days of completing this inspection. if the system is a s.s'=- o; has a design flow of 10,000 gpd or greater, the inspector and the system owner shah report to the appropriate regional office of the DEP. The original should be sera to s.st i ; 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. L4(V/�11Itr' J/D _l t�inso 03.0E v Title 5 Official Inspection porn:suk_^=_ce , e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _� -_- Property Address Owner Owner's Name information ism reouired for every page. City/Town State Zip Code Date c ln,s.ec-1 B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) Syste asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass' section need to -De replaced or repaired.The system, upon completion of the replacement or repair, as aoproVed ':)y 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 ot) is structurally unsound, exhibits substantial infiltration or exfiltration or tank fail'4re ;s immine a. System will pass inspection if the existing tank is replaced with a complying septic tanf as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound: not leak nu are" a Ce i�:C= 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 i:n ti"ie ci_'^i✓u i ! �cx to broken or obstructed pipe(s)or due to a broken, settled or uneven Pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•03%09 Title 9 0`ri 1 In=oec:ion F_. Subset Commonwealth of Massachusetts irl :r Title 5 Official Inspection Fora 1 Subsurface Sewage Disposal System Form - foot for Voluntary Assessr e 02 Property Address AC GO t,/G O%vner Owner's Name / information is �N'f P✓yl `/e s'� 6,r —1 9 O required for — , every page. CityfTown State Zip Code Dare cf ins ection B. Certification (cunt.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed oipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: N/ C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determ ne ;f 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 .,etland or a sEl'i s' 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 (S, S) 77 00 feet of a surface water supply or tributary to a surface %Y2:er s. U i ❑ The system has a septic tank and SAS and the SAS is within a %one supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet. v. supply well. SinSp•03/0? iit',a 5 officia.in so-d"In'For c;,_,jff=_= Commonwealth of Massachusetts -F irk Title 5 official Inspection Form r� i Subsurface Sewage Dispose! System Form - Not for Voluntary P,ssessmer:s Property Address��/ i' '/c �row� �► p Owner Owner's Name � /��,' / �1/JQ ©p�63p� p� information is (^Te I e- _ /��� required for State Zio Cod= Jat=of every page. City Fown y v B, Certification (cost.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fee 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 conform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to c' less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis mus , attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"too"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due clogged SAS or cesspool Discharge or ponding of effluent to the surface of the orcund ^r s' ece ❑ due to an overloaded or clogged SAS or cesspool ❑ r—ll��/ Static liquid level in the distribution box above or clogged SAS or cesspoo! _ Liquid depth in cesspool is less than 6' below invert o; ❑ E--`� than '/2 day flow _ Required pumping more than 4 times in the last year N✓1 uz El 2/ obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below F;ic' ire .= Any portion of cesspool or privy is within 100 `eet of a su=Go= ❑ tributary to a surface water supply. '.S:nsp•C3iC8 Tf;lee0`lcial!r.>�=_di� r_. ,.:5'�---..---- ==-'---- = '—'_-° -- - Commonwealth of Massachusetts g Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ien-s MEW - Property Address / Owner Owner's Name // Q information is C__e V, required for of ;ap_ ,or; every page. City/Town State Zip Code Date B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ [e" 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 v titer supply ❑ Ll�' 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 \,pater quality analyses. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- O,000gpd. The system fails. I have determined that one or more of the above failure El ���� criteria exist as described in 310 CMR 15.303, therefore the sys em: 'ails. The system owner should contact the Board of Health to determine what will, r necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either yes" or"no" to ,.tic:: of ,:.. ,o ..•:•;:ic. i.+ questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking '_',later suc ❑ ❑ the system is within 200 feet of a tributary to a sur,'ace the system is located in a nitrogen sensitive Brea ell"•= - ❑ ❑ Area — IWPA) or a mapped Zone Il of a public e`! If you have answered "yes" to any question in Section E the system iS CoriS d r u - or answered "yes" in Section D above the large system has fail=d. The ,�. ,;r,yr,yr cC- =; u system considered a significant threat under Section E or failed under Se lien D s : l! u _ra system in accordance with 310 CMR 15.304. The system owner should coat=ct. t ,a a "�c'iGe regional office of the Department. t5in.sp•03108 Tr.ie 5 oficPal Irs:?�_,ian=c:— c:_ ;::`e=e=e =__"__--_ =e—•=z____ _ Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage disposal System Form - Not for Voluntary A,ssessi-nests a==L rAJ Property Address Owner Owner's Name _ information is CPHr✓/lam L9ol6,Td- required for every page. Citv/Town State Zip Code Date C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the fe'ior: r Yes No / ❑ Pumping information was provided by the owner, occupant, or Board of Hey t^ ❑ Were any of the system components pumped out in the previo s t,vo Ae J ❑ [� Has the system received normal flows in the previous t,:,o week period? Have large volumes of water been introduced to the system recently or as part 01 ❑ this inspection? Were as built plans of the system obtained and examined? (If ti^ey v,,ere 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 t r inspected for the condition of the bales or tees, material of Cori struc ion, dimensions, depth of liquid, depth of sludge and dept^ of scum? �❑ Was the facility owner (and occupants if different from r.,er` provided w':-h ^ information on the proper maintenance of subsurface se'Alaae disposal sys;e—.s' The size and location of the Soil Absorption System (SAS) cr: -he site `-Ss been determined based on: ❑ Existing information. For example, a plan at the Bcarc o- Determined in the field (if any of the failure criteria releted to - ❑ approximation of distance is unacceptable) [31,0 CP:i? 5.3-02(= ? 'Sin,a•r3/08 Tite 5 0-dal Commonwealth of Massachusetts Title 5 Official Inspection Form i I Subsurface Sewage Disposal System Form Not for Voluntary Assassme7its Prope-ty Address Owner Owner's Name inio"Mallorl IS Ile- 0 required for State Zip Code 0-i every page. City/T own D. System Information Residential Flow Conditions: ...... -of bedrooms (actual):Number of bedrooms (design): Nurnbe, ! I.� //_V DESIGN flow based on 310CMR15.203 (for example: 110 gpd x# of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes No -- Is laundry on a separate sewage system? [if yes separate inspection required] I I Yes I' r10 L4_ Laundry system inspected? J_1 Yes .0 Seasonal use? Yes 0 Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Yes 7T__<�o Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons -,er H-2y Basis of design flow (seats/person&/sq.ft., etc.): Ni 0 Grease trap present? Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? les C, Water meter readings, if available: Last date of occupancy/use: Date Other (describe): tsinsp-03,106 Tile 5 Offid a!lnz:,eni On S,_ S-_­s n cS Commonwealth: of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen's Property Address Owner Owner's Name �oZ6 infornztion is required ror (� State Zip Code _= or "s -c`or. every page. City/Town D. System Information (cost.) General Information Pumping Records: Source of information: /v Was system pumped as part of the inspection? I es If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S em: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if ❑ Innovative/Alternative technology. Attach a copy of the u-rent oceration ar.b maintenance contract (to be obtained from system owner) an: a cony of inspection of the I/A system by system operator under, contract (❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source Were sewage odors detected when arriving at the site? — — t5in5P•03;08 Title 8 0`iCia!r�e;;erier.-p:-.;c�:;' ====' ::_'----` - -= _-- - -_ `C\ Commonwealth of Massachusetts � — Title 5 Official inspecti®n Form r= � ;) V 14 Subsurface Sewage Disposal System Form Not for Voluntary Assess ants v Propery Address Owner Owner's Names information is ////'� /'� 02 —�9' required for eve Page. City!Tovm State Zip Code Da`e os irpec:ion D. System Information (cont.) Building Sewer (locate on site plan): c�2 A i/ Depth below grade: feet J Materi of construction: cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting: evidence of leakage; etc.): Septic Tank (locate on site plan): Depth below grade: feet Material o construction: ❑ metal ❑fiberglass ❑ polyethylene o �r (ex l2'n) c0ncret — If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a cop+, of certificate) Yes i_! No ------------------------------------------------------------------------------- SIX Dimensions: Sludge depth: c2 Distance from top of sludge to bottom of outlet tee or baffle — Ze 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 �6F How were dimensions determined? 5 HUE 5 0�Clcl I nSpeC'iOi1 F.'?.'. Aso•03lOS - Commonwealth of Massachusetts Title 5 Official Inspection Ferrer�., p _-�=� 1 _= W Subsurface Sewage Disposal System Form - Not for Voluntar/ Assessj:,er^ts s.—_Y/- 9S AA, PC) Property Address Owner Owner's Name information is reauirad .or every page. City/Town State %ip Code Date of inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural irtegri v, liqui levels as related to outlet invert, evidence of leakage, etc.): 2vt PO 1 '40 T Ga 4 4) v177 e �i Grease Trap (locate on site plan): Depth below grade: feet Material of constriction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑; ether (expia r). Dimensions: Scum thickness Distance from top of scrum to top of outlet tee or baffle — — -- Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: D2.e Comments (on pumping recommendations, inlet and outlet tee or bat_!e cordiJcr. liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate or site, Depth below grade: — - Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑1 po!,eth\.,iere - e e: =.._ :5in5o oa(os Title S Official!nse=.iin:'_.-...,,---- < Commonwealth of Massachusetts i== Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessmerfs - `. property Address Owner Owner's Nam 1� / information ism required for eery page. City/Town state Zip Code C?`e or inspection System Information (cont.) Tight or Voiding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: i Yes I No Date of last pumping: pate Comments (condition of alarm and float switches, etc.): ttach copy of current pumping contract (required). Is copy attached? ❑ Yes Distribution Box (if present must be opened) (locate on site plan): �- Depth of liquid level above outlet invert --- Comments (note if box is level and distribution to outlets equal any evidence of so':i s c evidence of leakage into or out of box, etc.): / rl(I ump Chamber(locate on site plan): Pumps in working order: i Ves Alarms in working order: Yes — isinsp•mm Commonwealth of Massachusetts ..; Title 5 ®f iceal Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assess;mems Property Address Owner Owner's Nam- information is / j� ►�v!Ile id, C-R— J 9 —0 required for ever}'page. City/Town State Zip Code Date of 1nspec4;cn D. System information (cont.) m s and aocurtenanoes, etc.): Comments (,note condition of pump chamber,condition of pu p Soil Absorption System (SAS) (locate on site plan, excavation not required). If SAS not located, explain why: Type: leaching pits number: ❑ 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 pondln . scil. vegetation, etc.): /C/0 .Si ^s o7 f�5 c%� /!� ��. /H re- 5inso TJe 5 0`,cia!In-o=ctLc Commonwealth of Massachusetts 7, Title 5 official Inspection For m Subsurface Sewage Disposal System Form - Not for Voluntary Assessrn ILs Property Address Owner Owner's Name_ information is �`� .4r-y1//— ( 6 - C,:Z 9—� required for every page. City/Town State Zip Code Date c-Insoect:on . System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool — Materials of construction Indication of groundwater inflow ❑ Yes No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): /v Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level, of pondnc, con-tit n 3f etc.): f5insp•MOB Tittle 5 Ofici=l u �\ Commonwealth of Massachusetts Title 5 Official Inspection Form l i- Subsurface Sewage Disposal System .Form - hot for Voluntary Assessmena Property Add Owner Owner's me / - information is � Ile- QO3,-�- 02 — 0 required for State Zip Code Date r!nspec on every pane. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system includi�--,• -ties to at least two permanent reference landmarks or benchmarks. Locate all ':veils vvahin '00 feet. Locate where public water supply enters the building. Q G CI - 3� ,Q41 - 3� o/lip t9nsp.03!os Title 5 Official Insoae6on F3rT.: Commonwealth of Massachusetts Title 5 Official Inspection Form =!, rl Subsurface Sewage Disposal System Form Not for Voluntary P.ssess:;:ena _. Property Addre Owner Owner's Name information is required for A, every pace. City/Town State Zip Code Date o-,r.speonor D. System Information (cons.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design p!ans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with I I B Parof ealth - explain: ❑ Checked with local excavators: installers - (attach documentation:) ❑ Accessed USGS database - explain: You mu t describe howJ�ou established the high ground water elevation: fP/ Cr7— Jif /OC�, ��i?�-, � s W10/40 7 :� _ t5insp•03/o? Title 5 Official Irs—cton Se_sv= Sava=-= -a-.❑_ -_ J 7/y - 7 f� Y 1 � 74 THE COMMO EALTH OF MA$SACHUSETTS' BOARD OF HEALTH �� I _................ .. __.... --- ..OF.................... . Appliration -for Miipoiittl Workii Tatt,fitrurtion Vanift Appli is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a 1'�o%r - <��� �� ':/� X91 /✓ay �[ ►o- C If Loc tion-Addr s or Lot No: �✓� _ S_ _ _ o c✓ezyi------------ ............................................... b .. . .................. Ow , Address f ---------- ----•••-•-•- ---------•••-------••-••--••----- ------•---•--•--- '------------------ --- Installer r Address Type of Building �,� Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms-----------I----------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ----------------------------- No. of persons---•------------------------ Showers ( Cafeteria ( ) d Other fixtures -__ - ' ,_ - -- ----•. ... .................. W Design Flow-----------------------J ..gallons per person per day. Total daily flow....................... ....................gallons. W Septic Tank--Liquid capacity1,Z..._..gallons . Length................ Width ---- ......... Diameter._.-_.--_-__-_ Depth................ x Disposal Trench—No. ................�'Width------------- t< Le h�__ __ _._ Total leaching area------------.-------sq. ft. Seepage Pit No........� Diameter/��_-. epth Blow inlet____________________ Total leaching area-------.----------sq. ft. Z Other Distrib 'on box(,k-_� i ; Dosing tank ( ) Percolation Test Results,. Performed by................................................... 4z............... Date............. _____.___ Test Pit No. 1_ _� _._minute , r inch Depth of "l estt Pity "`---- Depth to ground water. �._ f'�• ' � (� -$ik 111 2.� .�ni;h„iP�'.P, ;,, t, t Test D `, ........ V OF x l�ls•---- �- _ s -.--.��---� � � ��Descrip 'on o Soil, 7C .C� rt A� N y -----Y -i ------- -- r�rla '. ,�r/ 14 t UW _____-_________________________________________________________________________________•----•----_•._-__.-----___---_------___-___-____-_----_--_--.--_--.---•-.-_-.----_---_ . -- ---- E y!y -Nature of Repairs or Alterations—Answer when applicable........______________________________________________•--._-.-__-.-. ----••-----------------------------------------•-------.---••--••------------•--•_--••----•---••--------•--------•---------------•--•----- ---•-----•----•---------- T Agreement: FSS�ONAL ENG\ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accorda the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss d by the board of health. - �, Signe ---• ------- Date Application Approved By----- -- - -•-•-• • .. �� M ,---•-•-••••......•. Date Application Disapproved for the following reasons_______________________ ________•------.-------.--------..-.--.-.-.-.---..--------.--._.--Q.-- ................ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo.....................................................--- fasued-•;-=................................................... Date TH.E.COMMONWEALTH OF MASSACHUSETTS ABOARD HEALTH .OF u��tt Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System N , F'h .a'- tsocation-Address , o t No. ----------------- ................................................................................................ Owner Address ------ . Installer Address UType tpfZuilding ;• Size Lot...........................Sq. feet g— .....................Expansion Attic ( ) Garbage Grinder ( )rwellin No. of Bedrooms__,_;_________ _________ per-, Other—Type of Building -------- Nd. of persons__________________________ Showers — Cafeteria -" \,Other fixtures ------ - ---- - -•-----------=-----------------------•••--•---•----------. .._------------- .................. „Design Flow `•_. .____.gallo s" per person per day. Total daily flow-----.......................................gallons. WSeptic Tank—Liquid capacity_--____---_gallons Length---------------- Width---------------- Diameter---------------- Depth___-_-_-.----. x Disposal Trench—No. _______________ Widtli-------------------- Total Length-------------------- Total leaching area---_--._-__.._-___sq. ft. Seepage Pit No- :_--__ Diameter____________________ Depth below inlet.................... Total leaching area-------.----------sq. ft. Z Othei;`Distributiori`box ( ) r Dosing tank ( ) r ! ~' Percolation W t Resul Performedwby..... ' - -- "" --- "`_�h --- _- _______________ Date----_----------------.- ---.--------- .jd ,,// ,� ,tea Test .Pit No. 1_ _�__minutelper inch Depth of Test Pit ��-(O- Depth to ground water.fyQ_ �Zar-'�., Pit 6q @@0 gr9!l4T '--------------------------'-- T .t ••------------ /♦ ------•------ ------ ................... ---- -- Desch non f dih /�' ,dA� a✓1.�uslr._. X.�..... _ Cxj ?f' > /�rY � t-._ `tl-� I'�'lls..ljf�'.. N of Mq ' W - ---. -- -'- s;. -- - --------------------------------- ------ ----------------------- Cr'� W o et��r , U Nature of Rep.iirs or, Alterations—Answer when applicable_-------------=----- -----------__-.-....__-_.---____---__ -. 0. o --- ----------------------------------- ------------------------------------------------- ------------------------------ The �dersigned agrees to install the a�oredescribed Individual Sewage Disposal System i the u Jovfsions of Article X.�,�of the State Sanitary Code- The undersigned further agrees not to plac cpp ation ntil a Certificate'of Compliance has been i ed b the board f health. . ., x M+ _ ___ _-_____ ......._ __ . .nets Date APplicatiori' APProved BY-.... ��, � jdf Application Disapproved for the followint`g reasons:--------------------------- ----------•--------------------•--•----------------------•----------- f __--•-•-` !� !ak Date PermitNo---------------•---••-•--------------•-=•---•----------- Issued...+................................................... � Date ` y THE COMMONJEALTH OF MASSACHUSETTS e •r' BOARD O HEALTH ...........OF........... .... ..... ... ........ 4 %:Prrtifira#r of wuutli�tnrr THIS IS TO C _ TIFY, That Ae In ideal Sewage Disposal System constructed ( or Repaired ( ) +J by '' ► 5 = �F Lft ---- - ----------------------------- --- -fi.,._ --- ---- Installer has ben instal d in ccor ance wrth�the provisi ns of Article XI of The State Sanitary Cod as described in the application for.Disposal Works Construction Permit No-------------_"7__�...3__---___ d�ed-..._1/���'.G_�-�'�--_---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A" GUA ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACT®R,Y.. J DATE -----------------------------------•-----------------•-------------`------_._ lnspector..........._................................................... ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH r ......OF........ No.. �t . Ririvlalittl �r � r�trtipt �"` +" Permission s reby grante4__7_____ --------x - --- -• -- -- --------.. ---------------------------------------------- i i to Constru ( or e ( ) n di,6 u Sew age.Disposal S s em at No.--- t csts -- tree' F as shown on the pplicati for Disposal Works Construction Permit 4..,d . ted.__. � _ ..�-------------- --- --- "'_ alth------------ ------._....---•-- DATE--- __ --,/;�-- ------ -----------=--•----- FORM 1255 HOBS_ & WAR EN.. INC.. PUBLISHERS *,: E DO LET 29 �� kj 75 01) 3 7� � 0 I A TOF �-- _ ZT "3 5 f h - - is - - e�• f. ' I •; i t 7 t f -, i e & d ALAN W. JONES & ASSOCIATES CONSU LTI NG.,ENG I N EERS Carleton Drive East Sandwich, Mass. 02537 Telephone 888-3154 TEST PIT AND PERCOLATION TEST October 13, 1973 - 1012O AM Tot Sea-Lake Corp. Personnel Presents Charles Merriam Route 6A & Tupper Road Alan W. Jones Sandwich, Mass. G2563 Test Locations 90' into- lot from ,:.Res Lot #28, Holly Hill Road Holly Hill Road layout Scudder Bay Centerville, Mass. 000" Ground surface 016" - To soil & vegetation Compact, fine, yellow sand, some small stone 21611 Firm, medium, yellow sand, some gravel and stone Average Percolation Rates 1" droD in.-1 minute 810" Firm, medium, white sand 11'6" t'e_ \'' OF No water encountered ALM 4. V. 116D F. T FSS/O,NAL a ' Water levels indicated, if any, are those observed when test pit was, excavated and do not necessarily represent permanent ground water. levels: