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HomeMy WebLinkAbout0139 LONGFELLOW DRIVE - Health 139 Longfellow Drive Centerville A= 189-112-001 SMEAD No.2-153LOR UPC 12534 smead.com • Made in USA F�ERI�NQ�SPaODUCit4& Sfl a:MM � soumo yJVJWSAFRO i 0 0 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is p required for Centerville MA 02632 September 22 2011 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 When forms on the computer,use 1. Inspector. ti( only the tab key I to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name ree 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 S1 12855 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Z, Passes ❑ Conditionally Passes ❑ Rll Q ❑ Needs Further Evaluation by the Local Approving Authority September 22, 2011 Job# 11-171 Insp ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority)(Bogt-21 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. 11-172 DeBenedictis 139 L.doc•08/06 Title 5 Official InspLW�lr Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is p required for Centerville MA 02632 September 22, 2011 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: Cesspool was pumped as part of inspection, overflow pit had 2' of standing water and a stain line indicating 10-12" of effective leaching. 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 11-172 DeBenedictis 139 L.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 September 22, 2011 required for P every page. Citylrown 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. 11-172 DeBenedictis 139 L.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for P Centerville MA 02632 September 22, 2011 every page. CitylTown 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 ❑ ® 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. 11-172 DeBenedictis 139 L.doc-08/06 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 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 September 22, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 ❑ ❑ 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. 11-172 DeBenedictis 139 L.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is p required for Centerville MA 02632 September 22, 2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ 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)] 11-172 DeBenedictis 139 L.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 September 22, 2011 required for P every page. Cityrrown 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 Number of current residents: 2 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 120,000 gal. _ 9 ( Y 9 (gpd)): 164 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. 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): 11-172 DeBenedictis 139 L.doc-08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 September 22, 2011 required for P every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Cesspool pumped annually. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Overflow pit installed in 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No 11-172 DeBenedictis 139 l.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 September 22, 2011 required for p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line'. feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 11-172 DeBenedictis 139 L.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 September 22, 2011 required for P every page. Cityrrown 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.): 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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 11-172 DeBenedictis 139 L.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 September 22, 2011 every page. Cityrrown 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.): *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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 11-172 DeBenedictis 139 L.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts - Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is p required for Centerville MA 02632 September 22, 2011 every page. Cityrrown 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: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: Two 6x6 pits. ❑ 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.): Original overflow pit had prevoiusly failed and was not opened. Newer overflow pit had 2'of standing water and a stain line indicating 10-12"of effective leaching. 11-172 DeBenedictis 139 L.doc-08/06 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 �M 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is p required for Centerville MA 02632 September 22, 2011 every page. Cityrrown 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 One with two overflow pits. Depth—top of liquid to inlet invert 6" Depth of solids layer 3" Depth of scum layer Trace Dimensions of cesspool 6x6 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Liquid level was found at outlet invert with no signs of surcharge. Blocks are intact and structurally sound. 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.): 11-172 DeBenedictis 139 L.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 September 22, 2011 required for eve page. City/Town State Zip Code Date of Inspection ry D. System Information (cont.) 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. Longfellow Drive •J\/•/\/•/•/\/•J•r•/\f\J•J\J•/\J\/\/\/\J\/\/\/•/•/\/\J\J\J\r•/\f•f\J\J\ 11 \f\J•/•f•/\/\/•f•/•f•/•/\f\/•f\/•f\/•f\/\/\/\f•f•f\/•/•/\/\f•/\f\f\J\!• 3/1 4/\/4/\/\/♦f4/4/\/4/♦/•/\/4f\/•/ / f\/\/•f f\/ f\I•/4f•/\/•f•f\ \/\r\/4J\/♦/\/\/\J\!♦f\/4r♦/•f\/♦J\/♦J\/•r\/•!\/♦J\'•/\/\f♦!\J•J\r\/\/\ 4f•f•f•/\/•r•J•/•/•f\J4/•J\/•J•r•J\J\J\J\J\/\J\/•/•/•/\r\J\f\r\f\/\J\/\ 50 2 63 28 Original Repair Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 September 22, 2011 required for p every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 15. Topo map shows property above el.40. 11-172 DeBenedictis 139 L.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �( 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14, 2009 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 I 1) forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 Citylrown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: a ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority c� ~ -; October 14, 2009 tea_ Ins ctor's Signature Date C) �- e t✓ ter' 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 v-4er the same or different conditions of use. 09 221 DeBanedidis.doe•08/06 Title 5 Official Inspection Form:Subsurfa Lo ce Sewag$es,osal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Longfellow Drive _ Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14, 2009 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Cesspool was pumped as part of inspection, overflow pit had 10-12"of effective leaching. 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 09-221 DeBenedictis.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s` 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14, 2009 every page. Cityrrown 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. 09-221 DeBenedictis.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 October 14, 2009 required for every page. Cityrrown 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 ❑ ® 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. Cl ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 09-221 DeBenedictis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the'system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 09-221 DeBenedictis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 October 14, 2009 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? \ ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ 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)] 09-221 DeBenedictis.doc 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 October 14, 2009 required for every page. Cityrrown 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 Number of current residents: 2 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 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. 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): 09-221 Deaenedictis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'l 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 October 14 2009 required for , every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Cesspool pumped annually. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. _ ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Overflow pit installed in 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-221 DeBenedictis.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ®cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 09-221 DeBenedictis.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14, 2009 every page. City/rown 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.): 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): Depth below grade: Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene eth of ❑other(explain): ❑ 9 P Y Y 09-221 DeBenedictis.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "t 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is Centerville MA 02632 October 14 2009 required for , 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.): "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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-221 DeBenedictis.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14, 2009 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: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: Two 6x6 pits. ❑ 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.): Original overflow pit had prevoiusly failed and was not opened. Newer overflow pit had 10-12"of effective leaching. 09-221 DeBenedictis.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14, 2009 every page. Cityrrown 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 One with two overflow pits. Depth—top of liquid to inlet invert 6" Depth of solids layer 3" Depth of scum layer Trace Dimensions of cesspool 6x6 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Liquid level was found at outlet invert with no signs of surcharge. Blocks are intact and structurally sound. 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.): 09-221 DeBenedictis.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yY 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14, 2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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. Longfellow Drive r r rrrrrrr r. r r r r r r r r r r r r r r r , , r , r , r r r , , , , , r , r r r , r , , r rrrrrr r r r r r r r r r r r r r r r r r r r r r r r r r r r r r,r♦r,r♦r\r♦r♦r♦r,r\r\r\r\r\r,r\r\r\r\r,r\r\r,r\r\r\r,r,r,r,r,r\r,r\r, r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r rrrrrr rrrrrrr r r r r r r r r r r r r rrrrrr rrrrrrr r r r r r r r r r r r r r r r r rrrrrr r r r r r r r r r r r r r r r r r ♦r`♦r♦r♦r`r`r♦r,r,r\r\r`r\r,r`r,r`r`r`r`r`r,rtir`r`r,r1r`r\r`r\r♦r\r` r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r i 50 2 63 28 Original Repair Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '. 139 Longfellow Drive Property Address Michael DeBenedictis Owner Owner's Name information is required for Centerville MA 02632 October 14 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 15. Topo map shows property above el.40. 09-221 DeBenedictis.doc•OaW Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 TOWN OF BARNSTABLE .,LOCAION T SSE#�nS ``- v VILLAGE &A-krV 1 ASSESSOR'S MAP&PARCEL II I NAME&PHONE NO. (2CO L(�)8_ 1—nJ SEPTIC TANK CAPACITY [ASS PP:� LEACHING FACILITY:(type) (size) I OM NO.OF BEDROOMSJp OWNER PERMIT DATE: E DATE: :,yP 101,q Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility). Feet FURNISHED BY . .r. . .r.{ 4 4 4 4 4 1 4 4 4 Y Y Y Y Y Y 4 4 Y 4 Y Y 4 l Y Y Mr.,OAF Y Y Y 4 Y Y Y Y 4 4 Y k Y+4 Yr4 4 4 4 Y Y Y Y 4 \+4 ♦ 4 4 Y \ 4 Y Y Y 1 \ \ Y \+Y 4f Y Y�Y rk 4 \ Y 4 1 1 Y Y Y k 4 4 Y 4 4 Y'4 Y 4 ? Y Y+4 Y 4 4 Y „�• - Y 4 Y Y 4 4 Y 4 Y 4 4 Y Y 4 Y 4 4 Y \ 1 +. Y 4 4 4 ♦f Y Y Y Y Y Y Y 50 2 63 28 Pr Original Repair L'v CAfION � `. SEW GE PERMIT NO. 13 o - f� V"I°L L A G E 46 INSTA LLER'S NAME & ADDRESS s C1M04A BUILDER OR OWNER DATE PERMIT ISSUED Zo 3I- 7e _ DATE COMPLIANCE ISSUED �0 �3� - 7 � I f , W j s z l� } No----- ._....... Fss.....V`................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............... . ... -.....OF................ .: ..................... ApplirFa#ion for Disposal Works Tonstrur#ion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............... ........ . .. 'N..l .L /..iz/?................. ••••••. ....... ...-•--•- t ..••....-••-•••-•---••....................••-- �j 4 L�oc�attiion- ddddrress l /�/� �p/� .......... C...:,C_L..... G.C1�iCt. ..lr.h.C.. ".. T °= (iyL. �' or o. -- ... --•t.�c _4.................................. A d ress W •---......-•----- v.�i.................................................................. a � Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of ersons.....__..............._._.__ Showersp ( ) — Cafeteria fixtures . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ w .......................................................................................................................................... .......... ----- 0 Description of Soil..............................................................................................................................--------------•-•••-- U ---------•-----•-•------•-••--•--••-•---••--------------•----••--......-•-••----••-.........-•---•-----•----••••---•---•-----•-•-•-•-----------••-•---•-•---•-........--••••......•---....--•••-•-----•- W x -------•---------------------------------------------------------------------- -•---••-•--•----•---•-------------------------•------••------ ----- V Nature of Repairs or Alterations—Answer when applicable..._.. %�/li-f� ..._ ... F.a/...... ��f,�r� --•-•--------------......................................-------------------•---.............----•-•--•-•---•-•-----------------••-•••-------•••-•••-•------------------------.........-•••-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal•System in accordance with the provisions of iIT .;,,. 5 of the State Sanitary de—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n ssued by the boar 1 Sign --- . ............. ---------------------- Date Application Approved By------.�-� ... . ... ,L ---------"--------..Da te---------------- Application Disapproved for the following reasons:...............................••-•--------•----..............................-----•---•--. ............» ......................................................................................................................................................................................................... Date f PermitNo......................................................... ..................... No.._....���_....... Fins.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF SALT ......_.... . �' "�j.l ...OF................. � ` ...................... Appliratinn for Dispati al Warks Cann.5triir#inn jhrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................ .....___ �F prk -J g l s� __....._.__---•-• ....-------- Location- dress r 0 W � �17 ON ddress :..................................... Installer Address UType of Building Size Lot...........................Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons......._,.__.:___.______._._ Showers ( ) — Cafeteria ( ) dOther..fixtures ----------------------------------------------------:.._..----------------------------- =... W Design Flow......._....................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter.............___ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter........I.......::... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing'fank Percolation Test Results Performed bY....................................................=` Date Test Pit No. 1_ --minutes per inch Depth of,Test Pit f=, Test Pit No. 2................. ............:....... Depth to ground water........................ ,..a .............minutes per iiicli" Depth of Test Pit" :___ Depth to ground water........................ ------------------------------------------------------------------------•-•-----•------•----.._...--.........................................................O Description of Soil----------...........................................................--------_------------- ----••••------ ------ x W .................•-••••----•-•-------•---------....••------------------------------.._..----•---------.....-------------------------------•--------------------.........----•-----•-•...-•--••-._...••. x ---------------------------------------------------------------------------------------------------- -••---•--•--- -- _-- _f.U Nature of Repairs or Alterations—Answer when applicable____.._ , C ---------------•••-----........_...•-------...••--••-•-----------------•-----•--•••----------••-•-------------------•--•---•-•••--•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary rVe—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be i sued by thee�«bb r 1 Signe _... .............................................. Date Application Approved By...... . ...................... ace...-•••••----•- ---------------•--••D ............. Application Disapproved for the following reasons.'......................... ----•-------...•--._..-------------------------------------------------..._.__....--- -----------------------•-------------•---..__...•-•-•---•------••--•-•--•--•-...................................................... Date Permit No_______________ Issued........................ - THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH� I Pio�. . .......0 F........ (9rrfifirtttr of Tomplizinrr IS IS TO CERTIFY; hat t ividual Sewage Disposal System c nstructed (/1-1(or Repaired ( ) by - f ............. -- Installe 41 ler } has been installed in accordance with hprovisionsr f _._..._. t e of T � of The State Sanitary Code.as described in the application for Disposal Works Construction Permit No._? .________ _____________ da.ted___f,} --_3/-..��-.......... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE a l SYSTEM VILL FUNCTION SATISFACTORY. DATE..............................................................-----••----•-_..... Inspector--................................................................................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rf" N A----- FEE...... ............... limns l` arks Tnnn is rruti# .>. .9 Permission is hereby granted-- -- -- /� ................................ to Cons t t ) epair ( an.4 dividual Sewage Dis SAtea o ...........0 SEreet as shown on the application for Disposal Works Construction PW No. _.�__.__. .. ated_./L _'` + ,�/ `•- -•__• Boar of:.Health DATE-•-- { '� "'. _./� ''................................... 1 FORM 1255 HOBBS & WARREN, INC., PUBLISHERS r+