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HomeMy WebLinkAbout0020 MADDAKET LANE - Health 20 Maddaket Lane Centerville A= 191 —073 S M EAD® Na 2-153LOR UPC 12534 anwad.aom • Mach In USA MANSWO (06Q) r Commonwealth of Massachusetts Title 5 Official Inspection Form > Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner owner's Name information is required for every Centerville ✓ MA 02632 5/26/19 page. Cityrrown 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. Important:When filling out forms A. Inspector Information 5 ,:F /$q 1>1 on the computer, use only the tab Robert Paolini key to move your Name of Inspector cursor-do not Robert Paolini use the return key. Company Name 67 Tanbark Rd. V�I Company Address Marstons Mills MA 02648 Cityrrown State Zip Code (508)280-9499 S14454 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 115.000); 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 5/26/19 inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t5insp.doc•rev.712WO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 f Commonwealth of Massachusetts @ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. Cityrrown 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: ® 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: 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 ❑ ND (Explain below): t5insp.doc•rev.7126f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form- Not for Voluntary Assessments a ,. 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner owner's Name information is required for every Centerville MA 02632 5/26/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y 0 N ❑ ND (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 failing 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: t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '� to Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 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 fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system asses if the well water analysis, performed at a DEP certified laboratory,for fecal Y P Y , P rY, 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is Centerville MA 02632 5/26/19 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 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. ❑ ® 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- 010 000 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 15insp.doc•rev.WM2018 Title 5 Official 4nspection Form:Subsurface Sewage Disposal System-Page 5 of 18 i4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5126119 page. Cityrrown 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 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. City/Town State Zip Code Date of 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: 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 Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes V No Last date of occupancy: 5/20/19 Date t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �7 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is Centerville MA 02632 5/26/19 required for every page. Cityrrown 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7126t2018 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1' 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.): Joints appear tight. no evideence of Ieakage.System vented through house vents. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner owner's Name information is required for every Centerville MA 02632 5/26/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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 GI. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 48»» Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 7- Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump every two years.lnlet and outlet tees in place.No signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form ^I� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. Cityfrown State Zip Code Date of Inspection 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 No Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level.Box has one outlet laterals with equal distribution.No signs of leakage. t5insp.doc-rev.7/2 612 01 8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. City(rown 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: ® leaching chambers number: 4 Infiltrators with ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (z 20 Maddeket Ln. Properly Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure. 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. Cityrrown 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.): I t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 chusetts Commonwealth of Massa Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN`R Owner Owner's Name information is Centerville MA 02632. 5/26/19 required for every page•. my/Town 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: Ej hand-sketch in the area below 0 drawing attached separately l 6_ 3 72 . 40 l 5/27/2019, 11:45 AM t5lra Wac.-rev.7/1812a1& TM8:5:Olfleielle peen;Form:SubsurtaoeSexmgal�sposalSysOBm•PagetBorlB c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for very Centerville MA 02632 5/26/19 e page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 15' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used USGS observation well data.Used technical bulletin 92-0001 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form w� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Maddeket Ln. Property Address GOLDING,KEVIN R Owner Owner's Name information is required for every Centerville MA 02632 5/26/19 page. Citylrown 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 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 t5insp.doc•rev.7/2612018 TOWN OF BARNSTABLE LOCATION 20DDA KE'I LJ-IA/6- SEWAGE# '6`3 261' VILLAGE 64G/k 960 LLC: ASSESSOR'S MAP&PARCEL I q I = 7 3 INSTALLER'S NAME&PHONE NO.`,4$g1AN eQAVA7h 02 4SZ56S SEPTIC TANK CAPACITY I ODO SAL LEACHING FACILITY:(type) INF -fWro l% (size) h 7 IP-,K 30. LF!� NO.OF BEDROOMS 3 OWNER kAIN 4 A 2LG E PERMIT DATE: COMPLIANCE DATE: �- 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 1 6� 2,:, 6'3' 33% 4°T 6 UT 2 0 - a 3 � z� dn4 AAADD4(el CAVC 615 -�3 F 1.&. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplitation for Misposal 6pstem Constril,* h Permit pplication for a Permit to Co struct( ) Repair( ) Upgrade( Abandon( ) -omplete System ❑Individual Components Location Address or Lot N . C A/40M f- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /'f/- �. s,,® Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size �i� sq.ft. Garbage Grinder( ) Other Type of Building .1zea No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �?7' Y3 gpd Design flow provided gpd Plan Date Oc..� , Z�Q Number of sheets I Revision Date Title v jZ4sjO.8 Size of Septic Tank / O �v/T[`a Type of S.X.S. c Description of Soil A_&ID 41bo. Nature of Repairs or Alterations(Answer when applicable) sv,QE3 ®e,n i7 -wo-c✓ rry 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 Tit nvironmental e a not to place the system in operation until a Certificate of Compliance has been issued by this and of Heal Signed Yn Date 76./ Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 3 Date Issued (6 —,4 No. 6l Fee { - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �., _ tE PUBLIC HEALTHDIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21ppliLation for Disposal *pstrm Construction Permit pplication for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ` omplete System Individual Components Location Address or Lot N .-Zo 1-1,4,044 L Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /91 C Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size 7/S E�/ sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd y Plan Date nr,." 7 e, Zg,!4—, Number of sheets Revision Date Title C 7 Size of Septic Tank Type of S. .S. — ,�,tt/ �� br Description of Soil /,�, I Nature of Repairs or Alterations(Answer when applicable) 444,.60 ,S o Caliper — %s C I' e 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 Titl�kh nvironmental �>fe[Rd not to,place the system in operation until a Certificate of Compliance has been issued by this B and of Healt, Signed Date d Application Approved by Date /6-9k ( 5 Application Disapproved by Date for the following reasons Permit No. 3 L Date Issued 1 6 —el- S THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned( )by Kat U N\a C�6('L I v }. � ��;. �o ynFAry,f 0 y\�f1 has been constructed in accordance kk with the provisions of Title 5 and the for Disposal System Construction Permit No.d0 '3 dated 16 ^�U Installer Designer #bedrooms Approved design ow 33o gpd The issuance of this petmit shall not be construed as a guarantee that the system will ncti n`as designed. Date Inspector G �� k s i ----------------------------------r------------------------------------------------------------------------------------------------------ No. _ ( l` Fee (CY) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit /'Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at (� 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 must be completed within three years of the date of this permit. Date �t� �2 Approved by LZS RECEIVED 11/03/2015 01:47PM 50e4325099 SPEAKMAN NOV/03/2015/TUE 01 :52 PM FAX No. P. 001 Town of Balrnstable Regulatory Services Richard V.Scali,Interim Director ' `"" Public Health Division. s654 ° Thomas Mclean,Director 200 Main Street,IYyantnis,MA 02601 office: 508-962-4644 Fax_ 508-790-6304 Installer&Designer Certification Form Date:, �� Sewage Permit#o�)/S L59 LAssessor's MaplParcel / ' 2 Designer: Address: S Address: / G ? On/b�,F1,1�f ,g�j, G d & issued a permit to install a (date) (installer) U septic system.at 0,�)O ',7��1 �� based on a design drawn by (address) signer) !/ 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was construct,�, —._."�liance with the terms of the pproval letters (if applicable) 4���t\OF 1gss"fit [7AVIL1 el NIASON 9; Installer's Signature) No-loss o U. �- S�1Nl rAi� (Design s Signature) (Affix Desi°gs Stamp(ere) PLEASE RETURN TO BARNSTABLE PUBLIC EMALTH DIVISION. CERTIFICATE OE COMPLIANCE WILL NOT BE ISSUED UNTIL BOTIC THIS I'ORM AND AS- BUILT CARD ARE RECEIVED B'Y THE BARNSTABI PUBLIC gEALTI DIVISION. THANK YOU. Q:\septic\nesigaer Certification Form Rev 8-14-13.doc Town of Barnstable UE Regulatory Services Richard V. Sethi;Interim Director { , Public Health Division 'rhomas McKean, Director 200 Main Street,>lyarinis,MA 02601 Office.: SN-M24644 F:m 508-799-6304. Homeowner Certification Form for Altern.rtive Svstems Property Address:_ 2_0 /trtA[))A VCr"C"r I A(,16 ,-- Assessor's :drip\Parccl. ly 1t2� Property Owners.Name: In accordance with Massachusetts DET alternative system approval letters, the following certification inforlaiation is required by the Owner of record. The Owner of record must place an '`x" in the applicabic box next to each lin,,-certifying the information. 1'es N\A l tray e been provided a cc� , tt:l the'I itle 5 llrl teeliiroiogy� �"�pprov I letters. p p, page Standard Conditions letter-and the specific technology, letter) l..h., •e been provided with the t���rrer's Manual ; vc bcera.provided with the Operation and Maintenartce Manual /For,Svsteurs installed under a Rernedial'U5e Approval, t agree to fulfill my responsibilities to provide a Deed?notice as required by 310 CM1R 15.287(lO) ap&the Approval Xl=or Systems installed under a.Remedial Use Approval,l agree to fulfill my responsibilities to provide csTitten notification.of the Approval to any nett Oxvner,as required by 310 CIAR. 15.287(5) _. If the.ciesi n does not provide for the use ofgarbage grinders.the restriction is understood and accepted Whether or not covered by a%warranty, I understand the requirement to mpair,:replace,modify or,take any other action as required by the Department.or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the enviconnient,as defined in_310 CMR 1.5,303 I ' rri � agree to comply with all terms and conditions above. 0 ,Property Owners printe arise iirlierty C)rvriets r .nature Date Note. This form must be submitted alona with the septic s vstem disposal works permit application for all RA 'ivskrnsIncluding new construction reps irsNu rades with and without aggregate stone and with conventional design criteria or credited design criteria. Q:1&,+ricAA hamcoi%nar cenitication.doc c Town of Barnstable Barnstable° Regulatory Services Department • snxtvsr�stae, * 1 ' � ' 16 Q. ,� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 3865 September 22, 2015 Jenna Arledge 20 Maddaket Lane Centerville,MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 20 Maddaket Lane, Centerville, MA was last inspected on 8/28/2015 by Paul Martin, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level, <12" below inlet(per Town Code 360-9.1) You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PEU;AORDER O_ _ HE BO OF HEALTH S., CHO Agent of the Board of Health ,® o Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\20 Madaket Ln Cent Sept 2015.doc c Town of Barnstable s�xt�srAaLE, �9 ,. Regulatory Services Department ArfD�,t► Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 65 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis.(This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code 3 60-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Parcel Detail Page 1 of 3 b r pry THE t ` o its Logged In As: �� Parcel Detail Monday,September 21 2015 Parcel Lookup Parcel Info Parcel ID j191-073 � � � I DeveloperLot LOT 22 "­" � Location 20 MADDAKET LANE"---"--.�.I Pri Frontage F 60 Se Sec Road Frontage Village'EENTERVILLE Fire District C-O-MM I. Town sewer exists at this address jNo I Road Index 0942 Asbuilt Septic Scan: Interactive , , 1910731 Map Owner Info o EWTJ —I Co-owner % , EA ARLEDGE,JENNA& BRENDAN L Streetl 20 MADDAKET LANE Street2 �.� City ;CENTERVILLE » State MA zip,0 6 Country Land Info Acres;0.36 ( use!Single Fam MDL-01 1 zoning SPLIT RD-1;RC ( Nghbd FO 105 Topography Above Street �a me. � I Road Paved w Utilities 1Public Water,Gas,SeptieI Location Construction Info Building 1 of 1 Year 1981 - Roof~ I Extod Shingle Built Struct wall Livin _ _ `_ _ Roof _ _ ,.-. AC �.�.._.�.... - Area+1008 I Cover lAsph/F GIs/Gmp ( Type. NOne 1 10 Style;Ranch ( wall Drywall I Rooms 3 Bedrooms I �� ` � 3,,,PTo,„2-1 _ �_ Int M Bath 3 Model=,Residential �HardZ d I 2 Full-0 Half Floor Rooms t Grade Average � Neat Hot Air I Total 8 Rooms Type Rooms & Stories}1 Sto ` _ Heat(Gas Found Poured nc.Co ry I Fuel ( ation Gross 34 -� Area Permit History---... http://issgl2/intranet/propdata/ParcelDetall.aspx?ID=13397 9/21/2015 Commonwealth of Massachusetts p W Title 5 Official Inspection Form imp Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r ey °M 20 Madaket Ln. PT°I Property Address Jenna Arledge Owner Owner's Name / Q1 information is Centerville / MA 02632 8/28/2015 �a�i required for every page. City/Town State Zip Code Date of Inspection GJ Inspection results must be submitted on this form. Inspection forms may not be altered in any ' way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 111217 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services _ Q Company Name 350 Main St _ Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority _ 9/4/2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. Cityrrown 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: B System Conditional)y y Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a,Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 20 Madaket Ln. G7M Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s): Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013=233gpd 9 ( Y 9 (9P )) 2014=238gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Truck Sight Glass Reason for pumping: Maintenance/Leach pit rest Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17 Commonwealth of Massachusetts - Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1981 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 25"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 20"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 1500Gal H-10 Dimensions: Sludge depth: 8-10" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 4-6" 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? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal H-10 tank in good condition. PVC tee in place on inlet with concrete baffle in place on outlet. Tank at normal level at time of inspection. Covers 20" below grade. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Madaket Ln. M Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/1.3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): H-10 DB-3 in fair condition. Box at normal level at time of inspection but shows signs of being overfull. Heavy solids carryover. Cover 76" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Jv - Title 5 Official Inspection Form IJ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Madaket Ln, Property Address Jenna Arledge Owner Owner's Name information is Centerville MA 02632 8/28/2015 required for every ------------ ..........------------------ --- page. Clty/Town State Zip Code- Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6x6 ❑ leaching chambers number: - - ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: - - - ❑ innovative/alternative system Type/name of technology: ------ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6x6 Leach pit with stone. Level was found less than 1'from invert of inlet pipe at time of inspection and shows si ns of berm overfull. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration �— Depth -top of liquid to inlet invert Depth of solids layer Depth of scum layer --- Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name information is required for every Centerville MA 02632 8/28/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +15'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger near pit to 15'with no water encountered. Bottom of pit at 9'. Minimum of 6' separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Madaket Ln. Property Address Jenna Arledge Owner Owner's Name requir atifore Centerville MA 02632 8/28/2015 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i i f Parcel Detail Page 2 of 6 N r Visit History Date Who Purpose 7/28/2015 12:00:00 AM Susan Ricci Cycl Insp Comp 4/9/2013 12:00:00 AM Jeff Rudziak Abatement Review 3/13/2012 12:00:00 AM Jeff Rudziak Abatement Review 7/27/2010 12:00:00 AM Paul Talbot Cyclical Inspection 3/24/2009 12:00:00 AM Karen Perry In Office Review 2/23/2009 12:00:00 AM Jeff Rudziak Abatement Review 6/18/2007 12:00:00 AM Nancy Finch Meas/Listed-Interior Access 8/21/2000 12:00:00 AM Paul Talbot Meas/Listed-Interior Access 12/15/1994 12:00:O0 AM IML 1 Meas/Listed-Interior Access Sales History Line Sale Date Owner Book/Page Sale Price 1 7/17/2014 BERGLUND, STEVEN E& KATHLEEN N C203944 $1 2 2/15/1990 BERGLUND, KATHLEEN N C119763 $1 3 8/15/1983 BERGLUND, STEVEN E& KATHLEEN N C92932 $0 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2015 $227,300 $45,300 $6,300 $683,700 $962,600 2 2014 $227,300 $45,300 $6,500 $683,700 $962,800 3 2013 $250,100 $45,900 $7,300 $844,100 $1,147,400 4 2012 $252,800 $44,700 $6,500 $1,124,400 $1,428,400 5 2011 $281,500 $6,200 $2,000 $1,124,400 $1,414,100 6 2010 $279,000 $6,200 $2,000 $1,124,400 $1,411,600 7 2009 $306,000 $5,200 $1,200 $949,600 $1,262,000 8 2008 $357,400 $5,200 $1,200 $762,200 $1,126,000 10 2007 $384,200 $5,400 $1,200 $762,200 $1,153,000 11 2006 $378,100 $5,400 $1,200 $733,800 $1,118,500 12 2005 $334,200 $5,300 $1,200 $684,900 $1,025,600 13 2004 $288,300 $5,300 $1,200 $440,300 $735,100 14 2003 $242,300 $5,300 $1,200 $260,800 $509,600 15 2002 $242,300 $5,300 $1,200 $260,800 $509,600 16 2001 $242,300 $5,500 $1,200 $260,800 $509,800 17 2000 $195,900 $5,200 $700 $180,600 $382,400 18 1999 $195,900 $5,200 $700 $180,600 $382,400 19 1998 $195,900 $5,200 $700 $180,600 $382,400 20 1997 $244,200 $0 $0 $146,800 $393,000 21 1996 $244,200 $0 $0 $146,800 $393,000 22 1995 $244,200 $0 $0 $146,800 $393,000 23 1994 $209,400 $0 $0 $146,800 $356,200 24 1993 $209,400 $0 $0 $149,600 $359,000 25 1992 $238,400 $0 $0 $163,100 $401,500 26 1991 $212,000 $0 $0 $199,300 $411,300 27 1990 $212,000 $0 $0 $199,300 $411,300 28 1989 $212,000 $0 $0 $199,300 $411,300 29 1988 $116,900 $0 $0 $60,400 $177,300 http://issgl2/iitranet/propdata/ParcelDetail.aspx?ID=19022 10/5/2015 r4 Parcel Detail Page 1 of 6 En 0:4 '�acrMw Logged In As: - Parcel Detail Monday,October 5 2015 Parcel Lookup Parcellnfo Parcel ID 258-078 I DeveloLoo� LOT 25 Location 139 SHEPERDS WAY I Pri Frontage '604 Sec Road ( Sec Frontage Village IBARN§TABLE Fire District BARNSTABLE Town sewer exists at this address No -l Road Index 1480 Asbuilt Septic Scan: 258078 1 Interactive 258078_2 Map K w` 2580783 Owner Info Land Info Acres 12.04 Use Single am MDL-01�I zoning R-2C _� Nghbd 0114 . Topography ILevel I Road Unpaved Utilities Gas,Well,Septic I Location Marginal View Construction Info Building 1 of 1 Year 1983 I Roof Gable/Hip Ext Wood Shiny le Built Struct_ p Wall g I _ Living 2982 "I Roof Asph/F GIs/Cmp I AC[Central I UK-2o- __ ® 1 Area Cover Type i �Z 1a12 style Modern/Contemp� In t D all Bed 4 Bedrooms a ® aTus a: F WallI Rooms B I _ gMT, Model Residential ( Floor Carpet Rooms-Bath 2 Full-1 Half a12a q, Grade Average Pj Heat Hot Ai Total g Type Rooms 4 ?? ' Stories 2 Stories �I Fuel Heat�Gas I Found-ation�' Oured Conc. Gross Area!�"5`580 Permit History Issue Date Purpose Permit# Amount Insp Date Comments 10/2/2013 Insulation 201306706 $2,500 6/30/2014 12:00:00 AM INSULATE 6/1/1986 Addition B29492 $25,000 1/15/1987 12:00:00 AM BA ADD'N http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=19022 10/5/2015 w Flynn, Judith From: Stanton, David Sent: Tuesday, October 06, 2015 8:09 AM To: Heath DeptMaiIbox Subject: 39 Sheperds Way, Barnstable: Well Late yesterday afternoon Tom Desmond came in for a well permit for said property. He said someone rejected it in the morning. I started to look at it and realized they had a failed septic system, in which I just did a perc test out there, closer to the well location. I explained to Tom Desmond that he should consult with the design engineer(Dave Mason) to make sure everyone is on board with the locations of both the well and the septic. I am going to e-mail Dave Mason to let him know as well. Thanks, Dave 1 r ; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the computeto r,use 1. Inspector: J only the tab key to move your Robert Paoliini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name rQ P.O.Box 763 Company Address Centerville Ma. 02632 0 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ` - y❑ Conditionally Passes ❑ Fails , ❑ Needs Further Evaluation by the Local Approving Authority 5/21/2009 � '' Inspe is Signature Date The system inspector shall submit a copy of this inspection report to the Approvi g Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a hared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner hall 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. �lol t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage isposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 20 Maddaket Lane M Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is-within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank,distribution box and leaching pit. Number of current residents: 1 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 2007:28,000 9 ( Y g (gpd)): 2008:29,000 Detail: 2007:77 gpd 2008:79 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 5/21/2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: - Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 0 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease.Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M °- 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching pit had 18"of water at time of inspection with stian line 39" below invert. 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts @ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code' Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where.public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately tl 01 1 1 �I 0 396 3 . y3 3� q , �9 qLl t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 35' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 20 Maddaket Lane Property Address Raymond Ruggles Owner Owner's Name information is required for Centerville Ma. 02632 5/21/2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 LOCATION L T �L`Z / IMF° >� VILLAGE CF,LjT'C Vl L.e Lff APPLICANT (3Al-lSI fie ? " F o= � b y a f ADDRESS 1�1T �elEL.Lo TELEPHONE No. a��(p/ � _7n r1(Nt�t���ref�, t1c�aY31� ENGINEER TELEP ONE:: 0.: - ^Z . DATE SCHEDULED QC�C` '�•� � I i �� �� � ` (Applicant' s sig'na_tuare' • • • . • • • • ! • o • • • • • • • o 0 0 • • • • • • o s • • a •'• • ! •.! � • • • • ! • e ! *:1! • • • • • • • • • !._a,o • •.1.• • ! !-! o • ♦ ,! !• •�f SOIL °LOG:. .. , r � SUB-DIVISION NAME_a "C` r � DATE 1t� •�� , � � . TIME EXPANSION AREA: YES NO ENGINEER TOWN WATER y' PRIVATE WELL ° i31, -- BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc..,dimensions of . lot, exact location 'of "test. holes and ' Percolation tests, .locate. wetlands in proxiMityr.to test holes ) : NOTES: AX - 1 P 1®. PERCOLATION RATE: LZ5'S " AQ p TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 1 +„ CAM 9k 1 . 2 T-0 P-b C214,,. 2 3 'tit 6-E-A��- 3 4 4 _ 5 5 6 6 7 8 '� I�. ' F�1J�1V N1 8 9 SAS 9 10 _ 10 r f. 12 ►.r0 �?�--�. 12 13 �- 13 14 14 15 .15 16. 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD ,r LEACHING PITS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: A . NOTE: ENGINEERING PLANS MUST SH OW NUMBER ASSIGNED ON PER TEST APPLICATION ORIGINAL: COMPLETED JN. ENTIRETP . AND RETURNED TO OAR OF HEALTH COPY! RETAINED BY APPLICANT �/s ?0- T ION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME & ADDRESS BUILDER OR OWNER f� ot,19CArIl DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED /2- �e-�j' ': d ,� `. �" 3'� �S . ri`���' . ............... .' THE COMMONWEALTH OF MASSACHUSETTS BOAR F E T H ApplirFa#iou for Disposal Works ustrurdinrt Permit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: GPI/:._ � L�� ... --... __. ........ .------ --- A ...Loc oOwL j}TesslsV V .. . .. l/ fires __ G'� �`T �✓!_/�L/ ------... .._�......:...:..lLd....J.✓. blf_.�....•�=11-. �../.......... .......... - N/ ............................. Installer Address � q! S feet � Type of Building Size Lot.`.....l__.�__ q. Dwelling—No. of Bedrooms.............. --------------------Expansion Attic ( ) Garbage Grinder W)C> `4 Other—T e of Building No. of persons a —Type g --------•----•-•------------ P 6............... Showers (�) — Cafeteria_( ) Q Other fixtures -------- -- Design Flow................. ._ ..............gallons per person per day. Total daily flow.._..a���.-d� ...............""......gallons. WSeptic Tank—Liquid'capacity/ff.VV..gallons Length................ Width................ Diameter................ De th...-............ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area- .......sq. ft. Seepage Pit No--------------------- meter--...__--___._...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ) II '-' Percolation Test Results Performed b ....._ .__�............. DatelQ_ ' .'. 1-..... a y.. XZA -------- ,�` ,a Test Pit No. 1.4..�___minutes per inch Depth of T t Pit../ ..... .... Depth to ground water<P/.Q .- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil...--"--- ........ �. .�.. �.V_ �P� - x �� o U --•--------"---"----------------------- V.----.••• . ----"--"---""-------------------".._..-"---------------......---.__---••-••._____._... VW ----------------------------------------�. ..... ----- �... --•-------------------...---••-•-----•------------------------•--------•-------•---__.__..._.-•-- Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•----------------------"---------.........."-------"------"------"------------------••--••••.......--•-•---•------------------•---•---•---••--••••----•--•----•--•----------•------•----•-•-•-.....-•-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'=LE 5 of the State Sanitary Code— The undersigned further agree not o lace the system in operation until a Certificate of Compliance ha en issued 4toard f 1 lth. new ,gyp Date Application Approved By...... • •---•- .-•'{•�"-- ... . ............................. ---••-•-• Z �...•--•--....... . Date Application Disapproved for the following reasons:-----"-------------------"---"--"----"----"---"-------"--------"-----------"-"-------•..._...-----.._........._ ..........................."------"-------"---"----------"-----"---"------•""------"--"--•-"-------"-""----•--------•------•----•----------------••----•----------•-••--------••----------•-••-••-•___.. Date PermitNo......................................................... Issued....................................................... Date %f .4Flcs........5..'.�......... THE COMMONWEALTH OF MASSACHUSETTS .—I— EOARDF E TH ` 0—." .....OF... ........�yS....... . ppliratinn for Diapostal larks aynstrnrtinn anti# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: a - a. ress ✓�v � OLo �j ---...... ..... ........ essw .. - - `-� .......... G__ - b.. ----------------------------------------------Lfi Installer Address 9 Type of Building '2, Size LotX .._9"�_P____Sq. feet U Dwelling—No. of Bedrooms.............. --------------------Expansion Attic ( ) Garbage Grinder (rV)r-> Other—Type of Building ......... No. of persons........ Showers — Cafeteria Other fixtures --------•--------------------------------•----- ......... ----------------- W Design Flow...............:... _.. gallons per person per day. Total daily flow..... . _..._____._...._.__.__.gallons. WSeptic Tank—Liquid capacity�(�U_.gallons Length................ Width................ Diameter................ De th....._.......... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.z: ►......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.......z.._.............:.. _...... ... ................. Date!-��___..__....�_..`__._.._C.?._ _.. 01� Test Pit No. 1_ __y_._minutes per inch Depth of T t Pit_/. _..... . Depth to ground water-A.10AjiCL. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------- Description of Soil. ' ----- ` =V ......................................... - J ---------_-•-------•-----------•-----------------------•----------.......-----•-•-•--•. x -----------=----/-x......... -•-----• -•. ..... .. U Nature of Repairs or Alterations—Answer when applicable..............................-...._....__...................................................... --------•--------------------------•-------------•-••------•---•----•---•--..............-•--•----------•---•----------------------...-•--••---------...-•-----•-•--•--...-------•---••-----........---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agree,$ not-lace the system in operation until a Certificate of Compliance ha en issued by t oard f��lth.�� 12- D to Application Approved By...... ......--•---•--••• -- .........�Z...->`-��'`-- Date Application Disapproved for the following reasons:................................................................................................................ ...........-•----------•--------------------••-•-------•----.................------------------........_....--------------------------•-•-•---•-----------------•----•------.--------................... Date PermitNo--------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS �..— BOAR F H TH Trrfifiratr of ToutpliFanr THIS IS_"T_0 CERTIFY, hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) -' ........`fir " .....<. ..4=by :-....-- ----------------------•........................... • -------•-•---••-.....----••--•-----•-_.... at•--•---•-------•--------. •-•-----•---•---•----------- �.- ..... . _ 2� has been installed in accordance with the provisions of TIII;' . 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__....._�_.._....>..5.-.......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARF..........OF......F ............................. 7 No._ /.............. FEE_:.'.: ............. �i��r�a�tt1 �ark� �nn,��rnr#inn rrani� Permission is .-reby granted............. 'r�'�____._� ___..��a..................... _____ __ ____ __ to Construct ( ) or.Repair ( ) an Individual. Wage ispos System at No Street as shown on the application for Disposal Works Construction Permit No..................... Djated.......................................... p� B DATE.............................. d of Health /------• -/-�--•----•--••---•----•--.....-- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS , Lo-r 2 n/ I M="jw�z 0a N , < N �� + PJ s �p o Q 'Qt° Jl - Z H o /� NCA o N P �'� Q r g� r 1` AL ER;�F-tk . MORSE No.10951 p 'O• 3 (� ��s ONAI E��G tA 15,wo s'•F I F2or�rF�CE : tc LEGEND �-,AofAQ \ EXISTING SPOT ELEVATION Ox0 G. CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 ——— -v :toHN FINISHED SPOT ELEVATION for zz FINISHED CONTOUR 0 a 4 IN APPROVED = BOARD OF HEAL H �Hosu Rv��o y ,o,S.f13 DATE AGENT SCALE= /"- -ro l DATE =iz.- z - 8/ LDREDGE ENGINEERING CO. IN A5AYs0,DE CLIENT I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. Bio�9 BUILDING SHOWN ON THIS PLAN CIVIL LAND DR.Br=. PM CONFORMS TO THE ZONING LAWS ENGINEER SURVEYOR OF BARNST LE, MASS. 712 MAIN STREET. CH. By HYANNIS, MASS. SHEET_LOF 'Z Q1 ATEAEG. LAND SURVEYOR /1lOTE /F E17HeR 7AILE.SEP7/C TANK OR ?O FT. MIA(. /EffC/HING P/T ARE MORE 7714A:"/ 12"SELOW: /v FT. MIN• '" GRAOF� fa 24.0/AMETEK CoNCRET.� CavER` SNALL BE ,9J?DUGR7' TO 4,TAZ> �AN EX7R.g CO NCRCTE 4 w PYC P/PE t,+EA V y CA S T /RO/Y C o�/�R SH,4 L L a USED I . M/N. PLTCN !FIN DR/VElVAY L= l O2. r. •O'•" CONC'R�TE 2 • �liJv.• COVER * Z>& GLEAM .SANG 5ACh'FILL L/QU/0 LEYEL %r 2 L Y r M d. 4"CAST i • ► o a•IROPH PE '¢ M N.�TCIt. ` 1000 G.4L. 'e� l • • • ► • . • • e �p� WA5HFD SMNE %'PON J -T. SEPTIC TANK O/ST, • s , • . . . • • , • • r / I DEPTH • / r • • v o WASI/EO STONE • • • • •1 1 p o • , • • O 1./ • • • • • • r OD ?•;; - , • � PRECi35 T SEEPAGE • e• r / . • • • • • r D ••v PIT OR evL11 v !NIiBRT �.'LE✓.SIT/oNS 4-11 6,P. D. a �. • • I • . . / r . 41a o ��.s x i •o = -IB P C. G. • Ot/lLD/NG `9.o lNYERT AT FT. 549,E �,r c PrtcG N = 10 FT. O/A1►9. C CsEE TABLILATJDAV) 1/V4E7' SEPTIC TANK 912.9 FT, - DU'TLET SEPTIC TANK 2 7 fT. E INLET D/STR/8l?lDN BOX 9B•4- FT. SECT/GN OF GR4UNt7- TEI�C TAA1 E Ol/TLETDl STR/BtlT/ON mx 9 7.2 F INLET LEACHING PT I 9?•O SFN/AGE O/SPOSAL SYSTEM. Fr, TAB411-AT/ON LEAC/Y/NG PIT p/MENS/ON A 3 FT DES/GN CRITERl.� -SCAL.E : %' _ /�:o' Ot�f�[-xstvw -;8 � FT. NL//NSER Of BEDROOMS 3 D/MENS/ON C4_FT.(Mi+,s). �ReAOEo/sPos.+L uw/r 0_ SO/L LOG SOIL. TEST TOTAL E37-/MA'7-eD FLO*V 330 G.4L.1DAY SO/L TEST A/ SO/L M57-1002 NUMBER OF LEACJvlNG PITS �_ fELG°K 9915 �`-ELEY, pATE GF SO/L TEST 10 22'g EACH/NG PER PIT IS iv. H/tTNESSED SrJ QE1 J Ri S/OF L 6oTTOM Lz4cH/NG PER P/T�_so. �&M RESULTS PERCOL/►T/O!v RATE / �� Ml /NCH .{ 7°/CA/RATE A2N MJJV. lJVGH TOTAL LEACH/NG AREA SQ. FT. , AE1tGOLA --V,&CE-> rL,O tit t N N C(-{ .�► FT. ESER GEACNI N6 ARE SQ. Z-¢ R VE M E1) S. OF M, �9 P��t1 DF A,1,4 LC�T 22 - AAA D DA K T i or cyGN =�� G�t�ITEJaA LL=—BERT - �nOR EJae �Q o No.1'951 o ELOREDG�ENGINEER//VG-CO,/NG• 9os�GIsT6e��� tL •s 71Z MAIN Sr. NO SU �`�/GNALE�i !� NO GROUND Wi4TER !E/VCOU/VTERE� /+YA^�^�/s, MASS. Q GMO UV o YS/ATER AT FLEI/, Foa ND. �d I d l9 SHEET '1 OF 'L - + Cot7e. Gove t-S �.��C ?r C� oT7/�� cas-,- it-on or .__ _ - -- sch, -40 PVC a.. I l e w1mir►. i. Tin. n, washed itch 1 er s ! �+� peastol�e P /4 P /7 Y�o ► e P p "As per feed'' line C/ears Sa r►d 3"min. in V. " irly. e/, i�Li"•C�V.Sf7 der � � � ' 1. �j /•s�ne baste 1hV. a% c Iv. e e/. S is fat K ` i-�, t!' I✓ :: t . � F , " Y 4L7 /14 0 rJ in,�.,, ;�„roc,cashed,;sn�>'base�•: dust. v. at o r � b o�t +r t �� `/��117 � / - royr�d AV wco. er table. a/ev = C7 L� bof�alrl �'esf hole. e/ev = ' In . JAE r '� _. L� 0� -'"�'' ' r\i',6 �./< 1- c�i-' BE-n,�o 0 M S __ '7" 7` .,t._./ '_ t�.. C� G w �"E.:. ns e- ,/ /. /T N - �S E D• B`T'°. '� �' rj le _r -- t _. r'S #�ta�9��° ,� r _ B/e,1 P� coLf3T/all! ,E?RTE . -� M/til//NcH l r5 - :e S EP7M/C TANK CRPgCIT'r: GRL. J`�oG. E l HDL E Z /iC::TUAL `EP7-/C T•f4I.11' S12E : GAL e/= 51. ,, (�► /,., L A H ✓JG A P A UI /vl _T >m-��� L L L n + / (`-�fa L. 1 �I dot a,; \, � J f.9 lam.• i `.3 t M I 4.- e..,_� r' i','—p!I'4.l i e.....":^f F"..� i...P .. .- r:••.+''' �t,�'�q �` _. __ _ ct✓' � .! f /� --•."_'" � ..E S E V E L E- C H/N G C A P H 1 T Y GA L. 0 f WoekmgAJShl1F' PAO /'117ATF= R/l9LS CQAJF0,4E�M To .E.P. T E S � �0. . .."". .' .•. ,r� R ® THE• 7 O W AJ OF .. ?` +' . �(� � E S 19/V'D � EGUL AT/oAJS FC)R ,I ._._. .�.. � :. 1� " � S'UB S'UreF•ACE D/SPosAL ©Fp _. .. N� 1 S 19 AJ/ T A 12 Y S E fit/A G E•. � _ _ . _n._.. /-� Lj WITk4 OOAJIAJG /2EGULATIOMS 7:4�� 1 , } SHALL BE D&TE,2M1/VED S\r` BUILDING //USF'E CTok? � CoMMISS lONE•!Z. 3) C .0S r11UG RAID FINAL G!el9nEs SHHLL : EMA1AJ ESSEAJTI ALLY THE S)9ME. " ►� c� }�'7C��./ �� .q� 0770TIt D �I T 6A!F WE Z /A-!V,�5 1 tS��/� C�j,+� - B D. OF HE- ,9 L T H AGENT PLof11�,J O �y ram' O D G OIV ST)P, UGT/O/V ram' 731 �-- ` 7- lam' , t P "� 1, O, scalp �`) 4),q 7-°E : _ n,ZD )G DAVID �y L,..E G�N D ry A, g �y existincl 0.0 � �� SP �,rr��� MASON m r-or,•f our __ _. __ . No„39f02 ; �. L ►' + '° No.1066 _ existin`1 , 'y �` �' �l V �F •SLIP• Pf_' �i►'+. spo f e/ev. - a__�__o. $� f ` p r'op, -p i m C 0 1-7 7 {„ c;®.aw.ssn .nrvm. c,.r .-:r<,z.eunmin,.srs.:,,.s. ww....h.s:.ik..,.s_u,..z.:.r_..W z.s.. x..v.•,eu....• ,.._.acx.,au....,.Rams,:as,.us:.:•w...,4y::,.. y. ,._...,... „_",us.ac.aa,.rrai.....u.. . ...u.....moo•r+..u..,.. .e