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Home My WebLink About0019 KEEFE COURT - Health 19 KEEF COURT, CENTERVILLE A = ,1 'J Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any. way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name tab P.O.Box 763 Company Address Centerville Ma. 02632 remm City/Town State Zip Code (508)428-4028 S14454 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 1�,340 of Title 5 (310 CMR 15.000). The system: -71 ® Passes ❑ Conditionally Passes ❑ Fails,,j r ❑ Needs Further Evaluation by the Local Approving Authority z 2/21/2008 07 Cn Inspector's Signature Date ` t 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. 19 Keefe Ct.-12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is Centerville Ma. 02632 2/21/2008 required for every 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 19 Keefe Ct.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: , ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the.SAS is within 50 feet of a private water supply well. 19 Keefe Ct.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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,feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 El ® 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 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 19 Keefe Ct.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town. State Zip Code• Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No r ❑ ® 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. i 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 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 ❑ E 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. 19 Keefe Ct.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, M 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 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? ® ElWas 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)] I 11 Keefe Ct.•1110, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 . 2/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 i 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected?, ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:76,000 g ( y g (gpd)): 2007:84,000 Sump pump? ❑ Yes ® No Last date of occupancy 2/21/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No ( Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 19 Keefe Ct.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 i Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: J.P.Macomber Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: tank pumped 4/2007 for maintenance Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool 0 Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1991 Were sewage odors detected when arriving at the site? ❑ Yes 2 No 19 Keefe Ct.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 1, 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: 8'6"x4'10"x57' Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 2 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 12 How were dimensions determined? Measured L19 Ct.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ii1M Sey`e 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is Centerville Ma. 02632 2/21/2008 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.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle . Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): t Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 19 Keefe Ct.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts W . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G.M1, SBy`' 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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.): � I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 19 Keefe Ct.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: gl. ® leaching pits number: 1-600-600o 1. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ deaching 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.): Sandy dry soil.No signs of hydraulic failure.Leaching pit was half full at time of inspection with no stain lines above this point. 19 Keefe Ct.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 every page. City/Town State Zip Code Date of Inspection D. 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 E 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): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 19 Keefe Ct.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Map Page 1 of 2 Town of Barnstable_Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out J J J�In t I I - ! a � - _'! -,, 4 !F I}S 1 F; t 0 2Q Set scale 1° = 20 I Aerial Photos rnn"rinht Inn F_7nn7 Tn... of eAA All rinhtc rncen., http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=169066&map... 2/21/2008 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1M 19 Keefe Court Property Address Liam Cahill Owner Owner's Name information is required for Centerville Ma. 02632 2/21/2008 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: Bottom of LP 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USED:Gaherty& Miller model 12/16/94 ground water elevations.USED:USGS Observation well Date.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. 19 Keefe Ct.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable �p 1HE Tp� Regulatory Services BARNSTABLK ; Thomas F. Geiler,Director y$ muss. ArEo��A Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with an technical observation s and interpretations Y contained within this report. l In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. 8 MCI �9� � 3 Od - - j999 r � COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 19 KEEF COURT CENTERVILLEq Name of Owner JOHN ROGORZENSKI Address of Owner: SAME Date of Inspection: 3/9/99 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02536 Telephone Number: (608)664-6813 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:3/9/99 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY YEAR.THE LIQUID LEVEL IN THE PIT WAS WITHIN 16"OF THE PIPE. 19 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:3/9/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ i have not found any information which Indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection 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. NO 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 complying septic tank as approved by the Board of Health. NO 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). _ broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced NQ 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 revised 9/2/98 Page 2 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:3/9/99 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 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 facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n(a_(approximation not valid). 3) OTHER revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:3/9/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.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 X Backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:3/9/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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 part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:3/9/99 FLOW CONDITIONS RES113ENTIAI: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):I Total DESIGN flow: 44.1 Number of current residents:4 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n/a Sump Pump(yes or no): NO Last date of occupancy: nla COM M ERCIAL/INDUSTRIAL Type of establishment: n& Design Flow: nla gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):Na Water meter readings.if available:nla Last date of occupancy: n/a OTHER: (Describe) Wa Last date of occupancy: n/a GENERAL INFORMATION PUMPING RECORDS and source of information: NONE System pumped as part of inspection:(yes or no):NQ If yes,volume pumped da- gallons Reason for pumping: nla 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nla APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM WAS INSTALLED 9 YEARS AGO Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:3/9/99 BUILDING SEWER: (Locate on site plan) Depth below grade: iC Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n& Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Etta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MO Etta Dimensions: L 9'S"H 5'7"W b'10" Sludge depth: fi_ Distance from top of sludge to bottom of outlet tee or baffle: 2E 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: 14 How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY ONE YEAR. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: Etta Scum thickness: Etta Distance from top of scum to top of outlet tee or baffle:-a& Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n/A 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.) Etta revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:3/9/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n& Dimensions: nla Capacity: n(a gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:_nla_ Alarm in working order:Yes—No—: NQ Date of previous pumping: n(a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nla DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIOU113 LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nla revised 9/2/98 Page 8 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:319199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nla Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: -n& leaching galleries,number: -n& leaching trenches,number,length: n& leaching fields,number,dimensions: nLa overflow cesspool,number: n/a Alternative system: nla Name of Technology: _n!a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY PIT HAD 1 6'OF LEACHING LEFT AT THE TIME OF THE INSPECTION_ CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n/a Depth of scum layer. n A Dimensions of cesspool: n& Materials of construction: Wit Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)nIa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:n!a Dimensions:nLa Depth of solids: nIa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:319199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a �►c� g 04 DA AA a76 A. revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 KEEF COURT CENTERVILLE Owner: JOHN ROGORZENSKI Date of Inspection:3/9199 NRCS Report name: nLa Soil Type: n(a Typical depth to groundwater: n& USGS Date website visited: Wa Observation Wells checked: ND Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater n/a Feet Please indicate all the methods used to determine High Groundwater Elevation: XObtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers _ Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) 9 ( P 1 GROUNDWATER WAS DETERMINED FROM ENGINEERED PLANS AT 160"+ revised 9/2198 Page 11 of 11 TOWN OF BARNSTABLE ZC:�i' LOCATION �� (e SEWAGE # VILLAGE C� Q OW'A sL ASSESSOR'S MAP & L0' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (t ) _ Q(;'r ��` (size) 1606 NO.OF BEDROOMS BUILDER OR OWNER t PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: 3 �.01tcP, Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Oec� AA Da '� Rg� Ac U g of � a1 •. .i .♦,♦ 1 Y• 'a.5 ♦ ... • i .:tti.....* '.�.. .;ti:..n4 tl.C •/ `)/ $ //� • ♦. . .. TOWN OFV B S L 1+Ty(` Ordinance or Regulation QWARNING NOTICE 01 Name of Offender/Managers_ V �' / t)`�(r Address of Offender � MV/MB Reg.# Village/State/Zip -�' r�� I u�, 1fl A Business Name ,amp/pm, on /}��/„. �� 20_ Business Address Signature of Enforcing Officer Village/State/Zip Location of Offense \i �l� - /t� 9<�-t r r ~ oli fneV y Enforcin 'De �t DivisAion Offense P)(A Facts Pb ! }l /l 01A6PIY /C,--,t Al ./ f l ;i 1J 1 1l'�T3� 1114 015 �U MOO 9c- G" /A/W) A Nn �V97� This will' serve only as a warning. At this time no legal ac'tionY"has been taken. v It is the goal of Town agencies to achieve voluntary compliance of • Town Ordinances, Rules and Regulations..' Education efforts and warning notices r are attempts to gain voluntary compliance. Subsequent violatio.. s wi 1 re, ul't in appropriate legal action by the Town. Q� (,1 /�� IF ~ ' TOWN OF BA NS ABLE BAk= Ordinance or Regulation WARNING NOTICE PA r� Name of off ender/Managert Address of Offender P A�'' ��' MV/MB Reg.# Village/State/Zip .� f--- C :I � L?�, �1' t.f -. Business Name ��am/gyp x on , ', f 20� , r' Business Address "t Signature of Ent,orcirig Officer, Village/State/Zip Location of Offense ' s\ -' l.✓ �/�{ t °' � Enforcing 'Dept/D vis'ion Offense Facts''-Q1 A' . This will serve only as a 'warning. At this time no legal action 'has been taken It- is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are _attempts to gain voluntary compliance. Subsequent vi:olatio:ns will result in,, appropriate legal action by the Town. / , / TOWN OF BARNSTABLE Ordinance or Regulation .gA WARNING NOTICE Name of Offender/Manager,,. Address of Offender ( MV/MB Reg.# Village/State/Zip 1 j .�^"+ `, f r1� , q ."x ' °r .f�. Business Name (, '' am/pm,' on f 20( = Business Address - e , Signature of Enforcing Officer ! Village/State/Zip Location of Offense Enforcing Dept/Division Offense � ? � ' i �....!� �` I( ,,,,�.• F".+. J! r� � l"' � r �i ✓ { f '� a%1 Facts This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and, warning notices are i attempts to gain voluntary compliance., Subsequent violations will result in, appropriate legal 'action by the Town. �, �� ; ✓` 1`!� + /� o/ -3_ �d i ®TOWN OF BARNSTABLE LOCATION Ln- V 7 Kfe�t CO3j� �' SEWAGE 60V VILLAGE ASSESSOR'S MAP St LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY I i CbO C9`1110-S -00 .LEACHING FACILITY:(t7pe) •IO. OF IEDROO�iS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNERG`�l1e ' �� b.< <� DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,� _� �� ✓� _� `�� `�a 'c�, `1 v� _ _ � �� ,; ...� No �l Fxa............ � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .----�WI'.J............._0F.... �J. ..------.----.....--........------ Appliration for Dispaiial Works Tonstrurtion rrrmit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at_..___.._.Lo� .. A-6 - f .._... -- !!!�.- Location -[tyl�y��ress /j Or Ny�,�'j [�/��J ._.0(�ClJea�..._&(1 ... ................./ � .4a•..... �•;4w_ r r ►-1 .................... ... / ... pq / Installer Address f/ V Type of Building Size Lot-_l.l?.��...Sq. feet �r Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) `k Other—T e of Building No. of persons............................ Showers Pk —Type g P ( ) — Cafeteria ( ) Other fixtures .----••-•-------••--------------- ------------ - -- Q !e:..----...... .. Design Flow.................1.s7.... gallons er n r Jay. Total i� fow........... . ..... ths.w gn g P - PF u y x �o..... .......... to WSeptic Tank—Liquid capacity .gallons Length. ?..__.. Width:.__/0.. Diameter:............... DepthQ24q.... x Disposal Trench—No. .................... Width.................... Total Length............ ... Total leaching area..............,,,,'sq. ft. 3 Seepage Pit No........I........... Diameter......1 ..... Depth below inlet..3.E.A........ Total leaching area..?4. ..N.....sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Resul Performed by.. ....�-....��?.VAJ.ter............. ................... Date..../04! .... .......:. Test Pit No. -._......._.minutes per inch Depth of Test Pit../S_,?2....... Depth to grouncNater...AIdA),... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x Description of Soil.... .._....7 ...._...f..:.. 1...... tZ kY t.Sl1 Q---..-14D.-•-•--.......................................� 5 V .................................•--•----••••--•---••---•----•--.....--•---.........-•••--.....................--•-•••••---.......•------•----•---•-..._................... ........................... W x ---•--------•-------------------•--...-•-----------------•--.....------•-----•---------•••----•-----•---......---------..............-•------------------••-------....-•-•-•--•........._.........•..... s U Nature of Repairs or Alterations—Answer when applicable....................................................................:.......................... .......................•------.......................----------.....----•------••--------....................-•-------------•----•-------•-...............--•--..........----•...........-•-............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sy to Y9in accord with the provisions of AITLL 5 of the State Sanitary Code— The undersigned furt r agrees t place ystem in operation until a Certificate of Compliance has been 'ssued by th oard of healt or igned. l/ ..............••-•-. .1/` '� 1` .... - --- Da y Application Approved By..--. •-•---• .• .........................•-•---•------------•--- ..........I.��2. ............... Date Application Disapproved for the following reasons:............................................................................................................_.. .................................. ------......-----•----...................................................................................................... .... ... --......_..........---•...._...._ Permit No.--•-- ... ... Issued.............Z.Z......a.. D THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..... � Ga .............................. Tertif irtar of Taautplitturle THIS IS TO CERTIFY,, That the Individual Sewage Disposal System constructed (�) or Repaired ( ) by....t). _... 1 • .....-•------•...............•--•---.... - • .._.......... ,/ Installer at.. Y!_--•� �� ...... C. o ...-------•---•-•-••------------------------------------------------- has been installed in accordance with the provisions of T�0I. - 5 of.The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....................D L(.._... dated...........).1.. -?�.-..� ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS TRUED AS A C- 2NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. ,� �/ . /•/�. ....... Inspector" - � .-__..•------------------------ .. -------------------- .-.-....._<.,___,..,. -----.-_-----------------ir7 --------..,...,---- F THECOMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C>YG .......OF..... r-�i� .............................. No...�.........o FIE.--- Dispood-Vorko Tonotrurtion lierutit Permissionis hereby granted..._ Q! .--....---------------------••----........-•----•-••--------.....................................-- tu Construct .(,<) or Repair ( )�an Individual Sewage Disposal System iJi ........................................ .........:.............•......... V ¢ Street , as shown on the application for Disposal Works Construction Permit No.`. r..�?-C.2.-"-r Dated..- ................... ............................................................. l / Board of Health DATE.. /-..�.C....--•-•--••------------------------------ C Noc _...... t - FEs. J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ` HEALTH .......7r' w I..............OF.....6A .f5r &4f ................................. Appliration for BOVolittl Workii Tonotrurtion ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: ..... .....__...__.... r ��.. ................................u2.......------ ..................l(.....-- -......_ .......... .. ...... /A Location Addy s� 1 - / ...................• - ! :'� 7_ �f..e/�.lTit i� (ram �Q----•----•-----�..G�Y� ,. ------- ��.... �sY�:T..... 1 i Owner'- _ A�es�•s; A _... ..... Installer Address -� Type of Building Size Lot._A.3;53___.._Sq. feet ., Dwelling—No. of Bedrooms..........__________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons____________________________ Showers — Cafeteria Other fixtures .-------•--------•-•-------------- - Q �&.;---___.---------------------------------•--------------�--------__-_---_____________-_____-______ W Design Flow...............//"0..................gallons per_�erson pFr day. Total daily flow_.__..__.._,.___._ ...................gallons. WSeptic Tank—Liquid capacity.;k _gallons Length-06.4%!_..._ Width:_ _.1!.._ Diameter________________ Depth%S.. ... x Disposal Trench No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No........I........... Diameter.......l 2.__:_._. Depth below inlet. r_:) _..... Total leaching area__z�:_�:___.sq. ft. Z Other Distribution box (>Q Dosing tank ( ) Percolation Test Result Performed by.._____.�:.____.2� .................................. Date___.�o � �.� c3 r•-•--•1; * * - Test Pit No. 4�-._._....____minutes per inch Depth of Test Pit../_C�___..__ Depth to ground water.._�4.��rtJY_.. rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Chi �a ........ �.._... :...... ....-•-•--•••-•-•--•••--•••_.._. O Description of Soil-- ._......�-j!2' �. /fit l - IR'----_, C� •--.j��-....--M o 2 ,-54 f"J r? x ......_. --------------------------------------------------------------------------------------- -------------------------------------------------------------------------- -------------------•----- -------------------------------- ...................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ••.---•---•--------------•-•--••---•-----------------------••-•---•----------•-•-------.._..---------------....--------._._.-------------------------------------------------•--•--•••...•••----•-_.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste4m accordance with the provisions of LITLL 5 of the State Sanitary Code—The undersigned furwer agrees not fo"place t system in operation until a Certificate of Compliance has been.•ssued by the-�board of health. ✓�"'�%� = '�' ez Signed.. :4 ..__.. -•-•-/ /�- .. l /� .._. rr •.............. ........I--Da.......... l./ y ApplicationApproved BY .......................................................-------------- .......... Date Application Disapproved for the following reasons:............................................................................................................ -.. .........................................................•G---•----------•--------`...._..--•-----------•-•.._....---._.._.__....----•-•-•---..._....---•--•-----s---••. -_a`t`e* -------- Permit No.....• _..C.----- .--.---- Issued------------- D �� c-'► Date --------------------------- I r F,LO tl..Str.-r x' spot✓ �o � _� F-k -74ZO ' W lT►,te��'�T f �a�' Y f�G� 5 ,x neo►uN �'' � � `� -- t (- �-- � �r ! f I, pA?u►�-' MS �SJ Cam!n ��r.1 �LoM I--��Cf� �� A�•�'�'�-:',. Mur.�►UPAL Wblt�W, bvait�Pst� . 3, PIPE pl'oA. I/4'/r'T urJLGsS oT:ieewtsr=. NOTED. 4, C/ iG-�I.l I.L�.Cat,1Cy A�.l.t�t"GAST Lt1.417-5 - 5. P t to i t.i-rs u- P,�E MDGC �-Lo.7E2 n cr-Wr 1Z d � —`�``"---- - - —_____`_- C�, c..a r.;sTR UGT t ot•i D E TAt LG 76 F3£ 3+ i `� ! - '1 :T�11S 1��1. e�er�Pv�v wow o�!�`1 ar*iD�t�a�i�p►.107 r ` � T�� I �..� � u sEo >��erl��►.�sT.aw►�CT. of: t't&sTo. -�-tIF; L� !"� f Z 18 i �ze - 2� f 'u �I y�3,mod, L ------- Z r 1 w i v ( k ize'l' iiLj I 3 S i ._ ,. N . .- ,.. dl��1.fw'T TrG GU Cp�'(,II� Y I.4G4eD ST*k' j _< � �� ►- L TGt�I K_ t Cr&L Tbv l K oAve Reese�ic.E doWf7 t.l FED c f; C ►�fTt ;7r Co4 `(Des-�;otJZN, MbGoc, 1