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HomeMy WebLinkAbout0386 LAKE ELIZABETH DRIVE - Health 336 Lake. Elizabeth. Drive Centerville... 'P A. 227 018 n a No. 0 V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y�� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es fiplication for disposal *pstrm Construction 3pernrit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System [K Individual Components Location Address or Lot No. L4E6r1; G(_12A_4G- N DR Owner's Name,Address,and Tel.No. C`vr�tc' ERIG' VtZLG—etVes� C-�( J� Assessor's Map/Parcel aa-7 Q Installer's Name ddress and Tel.No.$OR>4-Z Z-?'P?7 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms fA i 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) �L �Q,�) (-{- ,(� -�OlC (,fir P_15 ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health-, Signed Date Application Approved by 14VUDate Application Disapproved by Date for the following reasons Permit No. _ Cjr��� Date Issued Y No. 1] LA O Fee THE COMMONWEALTH OF MASSACHUSETTS -Entered in compute PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plication for Disposal bps rm Construction 3permit ' Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System WIndividual Components t Location Address or Lot No. Owner's Name,Address,and Tel.No. 3;816 LAKC- Et.12A.;GTP D1k Assessor'sMap/Parcel ,� �'t/rctt CRIGs lJl7tG'rrN�� hEcJ�c31 f Tel. SOg�. ��,—�g esigner's Name,Address,and Tel.No. Installer's Name,Address,and T .No. D Type of Building: Dwelling No.of Bedrooms ih dA Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) I ZIA gpd Design flow provided q)/4 gpd ' Plan Date r 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) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ; Signed Date Application Approved byf- 1 Date 1 _ (/_ / y' ��-7 Application Disapproved by Date for the following reasons Permit No._� � / Date Issued /1 — .. i THE COMMONWEALTH OF MASSACHUSETTS dBARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(y) Upgraded( ) Abandoned( )by C�A�w.i i r,- y� ae � _ d d—, f� at �Q /4,V 6471 1 tLr1f r— has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. /Cl- dated ).a Installer(IA a�� � -� &CW CZ) Designer N)/Q #bedrooms IA Approved design flow A/�� and The issuance of this permit s all not be construed as a guarantee that the system will c io as desig Date Inspector ��� n 1 11? ______________ -___________________________________ No. / y f (/ Fee `2 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30isposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( U) Upgrade( ) Abandon( ) System located at ` �� �,eQ_ i � a —��ll � r` ,� ,� �,•� i i i 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 ust b completed within three years of the date of this permit. Date i Approved by 12/4/2019 ShowAsbuilt(1700x2800) 1►— .. ;6a TOWN OF BARNSTTABLE LOCATION_'T& �_, F Tb -�nL( e'SEWAGE Y VILLAGE CfT.�YL.11y``ASSESSOR'S NAP A LOTS -O INSTALLER'S NAME&PHONE NO. " '7 71 SEPTIC TANK CAPACITY 1&6,0 �qy LEACHING PACILiTYAlype) fiT (size) A/K NO.OF BEDROOMS �S _PRIVATE WELL-QgPUBLIC TER BUILDER OR OWNER^,-E r�4��.;',���s I DATE PERMIT ISSUED: 7i�Y•�- DATE COMPLIANCE ISSUED: ` VARIANCE GRANTED: Yes__ No i i f I . i i � I Lhttlps:/Titsg ldb.town.barnstable.ma.us:8431/H ome/ShowAsbui It?mp=227026&sq=1 1/1 Dec 0'�?2019 07:58 HP Fax page 2 OZ X(2: Commonwealth of Massachusetts , - Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y r 386 Lake Elizabeth Drive V� Property Address Eric Henderson Owner Owner's Name information is required for every Centerville(Craigville) MA 02632 12-4-19 " page, CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. \`\1`p1111u u I nnrhrr, OF ii Important:When `�� 9CA filling out forms A. Inspector Information S/wpt i- y on the computer, I °: JA M E S cN use only the tab James D.Sears = t key to move your Name of Inspector : v r„Z. cursor-do not c* ' = Capewide Enterprises use the return °� r�o.. Company Name ', •• C �` key. 153 Commercial Street ��ir�l nlmN 51?L.``- Ibl Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3• ❑ Needs Further Evaluation by the Local Approving Authority 4• ❑ Fails 12-4-19 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15insp.doc•rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page t of 18 Dec Q6 2019 07:58 HP Fax page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owners Name information is required for every Centerville (Craigville) MA 02632 12-4-19 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal.Tank D Box and pit. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑, N ❑ NO (Explain below): t5insp.doc.•rev.7t2snam Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 18 Dec Q6 2019 07:58 HP Fax page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name information is required for every Centerville (Craigville) MA 02632 12-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cons.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is falling to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Wnsp.doc:•rev.712WO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Dec 06 2019 07:58 HP Fax page 5 Commonwealth of Massachusetts vzTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owners Name information is required for every Centerville(Craigville) MA 02632 12-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fall unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other; 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Cl ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5inwdoc.•rev.M64016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Dec 06 2019 07:58 HP Fax page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name Information is required For every Centerville(Craigville) MA 02632 12-4-19 Paw. CltylTown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than '/2 day flow iT Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped; ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within.400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5lnsp.doc;•rev.7P2&2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Dec p6 2019 07:58 HP Fax page 7 Commonwealth of Massachusetts t p Title 5 Official Inspection Form Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owners Name information is required for every Centerville (Craigville) MA 02632 12-4-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered 'yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must Indicate "yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as WA) ® ❑ 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)] t5lnsp.doc.-rev.712&2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 6 of 19 Dec 06 2019 07:58 HP Fax page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name information is required For every Centerville (Craigville) MA 02632 12-4-19 page. City/Town State Zip Code Date Df Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal. Tank D Sox and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection [] Yes ® No information in this report,) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No s Water meter readings, if available(last 2 years usage(gpd)): 2017-13,000GaI 2018-15,000Gas Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc•rev.7(2612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Dec 06 2019 07:58 HP Fax page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name information is required for every Centerville(Craigville) MA 02632 12-4-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc.-rev.71`2612018 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System-Page 8 of 18 Dec 06 2019 07:59 HP Fax page 10 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name information is Centerville (Craigville) MA 02632 12-4-19 required For every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the IlA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed (if known) and source of information: 1992 / 12-2019 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: T- 10" feet Material of construction: ❑cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. t5insp.doc-ray.712WO16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal 5ystern Page 9 of 19 Dec OC 2019 07:59 HP Fax page 11 Commonwealth of Massachusetts �. Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name information is required for every Centerville(Craigville) MA 02632 12-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3'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; 1000 Gal. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-TapeSludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): . Tank at working level.Tank and outlet cover at 3'below grade w/inlet at 18". Inlet tee w/outlet baffle.No sign of leakage or over loading. wnsp.doc•rev.7l2612018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Dec 1.06 2019 07:59 HP Fax page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L v.. 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name information is required for every Centerville(Craigville) MA 02632 12-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5lnsp.doc-rev.7126r2018 Title 5 Dlfidal Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Dec Q6 2019 07:59 HP Fax page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form 1)19 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name Information is required for every Centerville(Craigville) AAA 02632 12-4-19 page. City/Town State Zip Code Date of Inspectlon D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches,etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-44" below grade w/one line out. Box is new 12-2019 w/cover at 6". t5insp.doc!-rev.T126/2018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 111 Dec 06 2019 07:59 HP Fax page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owners Name information is required for every Centerville (Craigville) MA 02632 12-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number. 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: tsinsp.doc•rev.712W2016 Titles Official Inspection Form:Subsurface Sewage Disposal System•Pege 11 of 18 Dec 06 2019 07:59 HP Fax page 15 Commonwealth of Massachusetts - , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson owner Owner's Name Information is required for every Centerville(Craigville) MA 02632 12-4-19 page. City/Town State Zip code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is a 4' precast pit w/3' stone. Pit at 3' below grade wlcover at 22". Pit is dry w/clean like new wall's. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.); t5insp.doc-rev.V215/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Dec 06 2019 08:00 HP Fax page 16 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name information is required for every Centerville (Craigville) MA 02632 12-4-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): t5insp.doc;-rev.712872018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 15 of 18 Dec q6 2019 08:00 HP Fax page 17 Commonwealth of Massachusetts qbTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments l 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name Information is Centerville(Craigville) MA 02632 12-4-19 required for every City/Town page. State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.Oo•rev.T/2612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Dec 96 2019 08:00 HP Fax page 18 k.F B 304 f3' — '5' 3Y r 4 Dec 06 2019 08:00 HP Fax page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form 1.UT, - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owner's Name information is required for every Centerville (Craigville) MA 02632 12-4-19 page. CitylTown state Zip Code Date of Inspection D. System Information (cont) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N-' 15'+ Estimated depth toFigh ground water: 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: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: U_S.G.S.well 15'+. Bottom of pit at 7' below grade Bottom of pit at 8'above well depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc rev.712012018 Title 5 Official inspection Form:Subsurface Sewage Disposal SysGam-Page 17 of 18 Dec ,06 2019 08:00 HP Fax page 20 ' r c Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 386 Lake Elizabeth Drive Property Address Eric Henderson Owner Owners Name information is Centerville (Craigville) MA 02632 12-4-19 required for every - - page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector information: Complete all fields In this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included GRAB . N�. Tde 5 Official Inspecdon Form:Subsurface Sewage 440sel System Page 18 of 16 15insp.doc•rev,7/2612018 COMMONWEALTH OF MASSACHUSETTS. r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s � V TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP - z-7 PARCEL Property Address: OZ9.�Z��a LOT I--l Owner's Name: Owner's Address:/ ' Date of Inspection: ? ? RECIVED Name of Inspector: (please print J EAI 41 OCT Z 11 ZOOZ Company Nam M J� - Mailing Address: .,., C� ,G! '`�0� if6 TOWN Or BARNs-rABLE HEALTH DEPT. Telephone Number, `7'7l. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address.and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site.sewage disposal systems. I.am a DEP approved system inspector pursuant tt Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further.Evaluation by the Local Approving Authority ` 4FIs 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 completingthis 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. Notes and Comments �c � �G?/I�Ci ****This report.only describes conditions at.the time of inspection and under the conditions of use at that time:This inspection does not address how the system will perform in the future under the same or different. conditions of use. Title 5 Inspection Form 6/15/20.00 page 1 Page 2 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:. Owner: Date of Inspection: QUA Inspectioni Summary: Check A,B,C;D or E/ALWAYS complete all of Section D A. S stem Passes: a. 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. �. I W Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair; as approved by the Board of Health, AJ11 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 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: 2 Page 3 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSUR.FACE.SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION(continued) Property Address: X Owner: _ Date of Inspection: 41� o?Q CJ'---;-- 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.10.0 feet of a. surface water supply or tributary to a surface water.supply: _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water.supply. The system has a septic tank and SAS.and the SAS is.within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a. private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 r r Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARV ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: w 'e" 2/upP Owner: Date of Inspection: / (>00 Oa D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ V 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 _ 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 portiomof a cesspool or privy is within a Zone I of a:public well. Any portion of a cesspool or privy is within 50 feet of a.private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is:equal to or less than 5 ppm,:provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form:] 1"0 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore.the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10;000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water.supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection,Area—IWPA)or a mapped Zone I1 of a public water supply well If you have answered"yes"to any questibn 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: C �'2 Owner: 0. Date,of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the followinz: 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 the were not available note as N/A P Y ( Y ) V _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? v _ 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? _V _ 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: Yes no Existing information. For example, a plan.at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: , wah V *i-&iV Z4"LQ Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(.design): Number of.bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence.have a garbage grinder(yes or nQ Is laundry on a separate sewage system (yes or nqh.,� f if yes separate inspection required] Laundry system inspected(yes or n4--I& Seasonal use: (yes or no)�' , Water meter readings, if available(last 2 years usage(gpd)): 6V Sump pump(yes or no): Last date of occupancy: Tj-,z h wyj• COMMERCIAL/INDUSTRIAI� Type of establishment: . Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): _ Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes.or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records C Source of information: V/ Was system pumped as.part of the in pection(yes r no :. If yes., volume pumped: gallons--How was quantity pumped determined? _ Reason'for pumping:. TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool _Overflow cesspool _:Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Appx�imate age of all components, date installed(if known)and source of information: Were sewage.odors detected when arriving at the site(yes or nok� 6 f Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION:(continued) Property Address: PA Owner: Date of Inspection: BUILDING SEWER(locate on site plant/)Q� Depth below grade: _ Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: v (locate on site plan) Depth below grade: - Material of construction: t�ncrete_metal_fiberglass polyethylene —other(explain) _ If tank is meta}list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Z Scum thickness: __ Distance from top of scum to top of outlet tee or baffle:_3 Distance.from bottom of scum to bottom qf outlet tee or baffle: . J How were dimensions determine Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert:,evi nce of leakage, etc.): GREASE TRAM) 0ocate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass__polyethylene_other (explain): _ Dimensions: Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity, liquid.,levels as related to outlet invert, evidence of leakage,etc.): 7 L Page 8 of 11 OFFICIAL_INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: Vv c� TIGHT or HOLDING TAN)l/rvv (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal . fiberglass polyethylene__other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,etc.): DISTRIBUTION BOX: (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 solids carryover, any evidence of leakage into or out of box, et : a , PUMP CHAMBER: A-(locate on site plan) Pumps in working order(yes of no): . Alarms in working order(:yes or no): Comments (note condition of pdinp`chamber, condition of pumps and'appurtenances, etc,): 8 Page 9 of 11 OFFICIAL ]INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner. .Date of Inspect ion° e . o o� 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 ponding, damp soil,condition of vegetation, CESSPOOLS (ce:sspool 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 Cr groundwater inflow(yes or no): Comments(note condition of soil,signs of�hydraulic failure, level of ponding, condition of vegetation,etc.): PRIW_,/)t 1"(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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: Qa .SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where'public water supply enters the building. 1 0 OD 10 Page l 1 of.I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address.,. Owner: Date of Inspection: (7.4�__ SITE EXAM Slope Surface water . Check cellar Shallow wells Estimated.depth to ground water feet Please indicate(check)all methods used to determine the high.ground water elevation: Obtained from system design plans on record-If checked, date of design.plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with,local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: n a II - I . Cornple;ed by: - t G G O•tJ�iC-lvA-�,� i �V _ C.OiVI�U i ATIO\ I Site Location: C l/ i'r�!•e��', moo: N°o.. Address: Contrac.or: .� �Q� i� ©//1✓�J`.gddres;: 5�[ � .G,! 1� � STD?.- i . Measure Ciep-Lb Lc-W'ater:able. ............ .Date . _. _ mo�tn%cay/year I ST-ER 2 Usine.Water-ravel.P;ange Lone and. I i.de.x W611:,I)A p:locate site-analeLe;nine: •A ;ppro.priate.index weiL..............._..__....__.....//.!�. .-.. I j S GJ;. Us:flGr•,Tnmtihly.repo.r . re�"Culp nt Water escu:Ces Ce�diLions" I'• I determine CUrrentL'deoth to. W'ctei• I�Yci for index wel-I �`'D� I �/ •�J �. �, - . T.O rlii%yeZr S-E — Usine.T abie.ci -W-at=-l.ev:=1 Adjustments _. or index well (STET 2.fi:;,:cument di-atn o water level fox.index wei.! (•STEP 3•)., and-v`'`ne-)e.ve zone {STS?2B) - ..............._...._._..._...- _....._..., I / de arm:.n� wat<: eve, aaics.tmen� .......,...:.:..._..__..:.. ZZ S.T:EAD 5 s_ima --dep i„ o.hian water by sobtracti:-:e tie water- level adjustment_(ST•=-P 4) iron neasurec.ceo�n ?o.water level at sr e.iS l'tP ........................................._...-.. -......_... ............ I�• Q E . O'er V THE COMMONWEALTH OF MASSACHUSETTS AppROVEO BOARD OF HEALTH earnstabie Conservation Win? TOWN OF BARNSTABLE Appliration for Dispaiittl Works Golan-ru.rti lerMit 0=0 Application is hereby made for a Permit to Construct ( ) or Repair jQQ an Individual Sewage Disposal System at: ......SP_ .......... .... .... ... f-A .. ..L. atio.. d.;S/ S�?/ or Lot N.! C/�^;� -(J--. Owner 7(� Addre Installer Address UType of Building Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms.:..........................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a Other—Type g ............................ No. of persons............................ Showers ( ) Cafeteria ( ) d Other fixtures ......... W Design Flow.................... .............gallons per person per day. Total daily flow............... a...............gallons. WSeptic Tank—Liquid capacity�1.�.Dgallons Length................ Width................ Diameter-------------... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_____---_--•------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........... .-------•_--- O Description of Soil------------------- 'Q.- /--•------L��4M......._CS_ k _�4�X 4...------. =----•.�� x V ......................................•----••---••--------•-•••--•••••--•--•--•-•••---•---••••-•-•-•--•••-----•••---•-------•-••••---••--•••----•-••--•------•---------------•-•-•-••---•••---•........_ W x •-------••-------------------•-----•-•--•----••••......-----------•-•-••-•. --••••......---•-•-- -•-•••-•--•-•-- --------------------------------------------------------------•---.............-- U Nature of Repairsr Alterations—Answer when applicable._Rw�..t"_.`Zz .. -. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance b n is ued board of health. — Signed ----- --- --- .............. ......fl Application Approved By . . -- ..... .. . ........... j Da Dace................. Application Disapproved for the following rear ......................................................................... .................................... ............ -----r--------- - ----------------------------------------------------------------------- --- . .......................................... --........... .....---...Dace----............-. Permit No. ... ........... .. ---- Issued Dace TOWN OF BARNS�\TABLE LOCATION.zg�, F"rai3�c�'r (),SEWAGE # VILLAGEIr-MCI te�t LAAC- ASSESSOR'S MAP & LOTt;lt7- 43,-%4 -7 7! INSTALLER'S NAME & PHONE NO. r2,--t ey—jr( &\CS T SEPTIC TANK CAPACITY LEACHING FACILITYArype) (size) sf y- r.}-, NO. OF BEDROOMS— PRIVATE WELL <PUBLIC TER BUILDER OR OWNERS DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �1 Y� , � �� ��� � �, ,�► r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Surks Tonsumdion jkrmit Application is hereby made for a Permit to Construct ( ) or Repair (r6 an Individual Sewage Disposal System at: r L on ddress or jot Np Addre� Installer Address Type of Building Size Lot----_--- Sq. feet �. Dwelling—No. of Bedrooms_-----------------------------------------Expansion Attic ( ) Garbage Grinder ( ) yP g ------------------- P ( ) — Cafeteria ( ) � Other—T e of Building ________ No. of ersons____________________________ Showers Other futures W Design Flow---------------------- -------------gallons per person per day. Total daily flow------------__13 -------___gallons. WSeptic Tank—Liquid-capacity l'?Dtgallons Length---------------- Width---------------- Diameter---------------Depth______-_-_-- x Disposal Trench—No--------------------- Width--------------------Total Length-------------------Total leaching area------------_--sq.ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet-------------------Total leaching area--------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------------------------------------------------------------------- Date----- Test Pit No. 1----------------minutes per inch Depth of Test Pit------------------- Depth to ground water-____-__________-___-___ 44 Test Pit No. 2----------------minutes per inch Depth of Test Pit---------------___ Depth to ground water-----------_----------- C4 ---------------------------------------------------------------------------------_ _--------- _----- -- O Description of Soil------------------� /---------- -J -_5 1 L.--------- - --� _- V ------------------------------------------ -------------------------------------------- ------------------------------------- ---- -- ------------------------- ------- W U Nature of Repairs` r Alterations—Answer when applicable_PZ -K_'_�- ----C15,SS ---------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance;h b n is ued th board of health. Signed - --------- - - -- - --- - �------------- ----- Application - Approved By &-, '��---------- ---&------------ - -- --- -- -------------------------- ------------- ------------------------------------- tDOW Application Disapproved for the following rear ----------------------------------------------------------------- --- - -- - - ------ --------- --- ----------------------- % Permit No. -----------<` --r-----j_0 Issued ----------� 0/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#iftra a of (ffoutylianre THIS IS TO CERTIFY, Tlta the Individual Sewage Disposal System constructed ( ) or Repaired ( by---------------------------------------------------- cS r-C7 0 Z.0- V - --------------------------------------at ------------------------------------------------------------------------- c%GC L— has been installed in accordance with the provisions of TI f The t ironmental Code as described in the application for Disposal Works Construction Permit No. __ __ ff_I_T__- dated THE ISSUANCE ISSUANCE OF THIS CERTIFICATE SHALL NOT SE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------- ---- ------- - =-L - ---------------------------------- Inspector -- v ---------------- - -- ------ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.__9 TOWN OF BARNSTABLE %puuol Mmks TunshmMan tJIApn ff Permission is hereby granted-------------------------`�-'d`(�G�O to Construct ( ) or Repair ( an Individual a Disposal System at Street � 1 c�as shown on the appli 'on for Disposal Works Construetio t No __�__ 1 t �_-- /1 D - Board of � DATE _ - - -- - —-r - -- - ----- T - FORM sssoe e w VIC..PtARUS tERS