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HomeMy WebLinkAbout0510 MAIN STREET (CENT.) - Health (2) 510 MAIN STREET, CENTERVILLE A=207-044 �J�,REGYC(FOCoy� III � Z N o 22�,,.,.�R HASTINGS, MN (*f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments,T . _01 510 Main Street Property Address j, JHR Wing LLC Owner Owners Name Information is Centerville t required for every MA 02632 3-26-19 page. City/Town State Zip Code Date of Inspection 1 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 Inspector Information133 filling out forms A. on th a corn puter, ygo DAMES m= use only the tab James D.Sears = rn key to move your Name of Inspector L): :y cursor-do not Ca ewide Enterprises use the return —� Q- key. Company Name? ?�TT�!�. �00 153 Commercial Street ���Frrs INSQ Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 CM 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; p�ect on; 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. ❑ Falls -_QO_424� 3-26-19 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. l5insp.doc-rev.7126/2018 Title 5 Dffidal Inspection Form:Subsurface Sewage Disposal System•Page 1 of 19 I• a5ed xeA dH LI•:L0 660Z 8Z JeW Commonwealth of Massachusetts hoz Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments r 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is Centerville required for eve MA 02632 3-26-19 page. Cltyt7Dwn State Tip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Anyfailure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and three chamber's 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If`not determined," please explain, The septic tank is metal and over 20 years old`or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ NO (Explain below): tfiinap.doc•rev.7/26/2018 Title 5 Official Inspectlon Form!Subsurtaoe Sewage Disposal System•Page 2 or 18 Z a5ed xe:1 dH L 6:L0 6 60Z 9Z JeW Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is required for every Centerville MA 02632 3-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cost,): ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms 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 ❑ 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: 151nsp.doc•rev.712612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 3 of 16 J £ a5ed xed dH LVL0 61.0Z 8Z JeW Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ev 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is required for every Centerville MA 02632 3-26-19 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 passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of,the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tfiinsp.doe•rev.712612018 Title 5 official Inspection Form:Subsurtaoe Savage Disposal System-Page 4 of 18 b a5ed xe� did L 6:L0 61,02 82 JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i ,v~ 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is required for every Centerville MA 02632 3-26-19 page. City/Town 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 1-11- i is less than 6"below invert or available volume is less than day flow AOr#tom' ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis, [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA, Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone I I of a public water supply well t5insp.doc•rev.7126/2018 TNe 5 Officia.Inspection Form;Subsurlace Sewage Disposal System-Page 5 of 18 t S abed xe:1 dH L 6:L0 6 60Z K JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is required for every Centerville MA 02632 3-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following foram 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.7/26 018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 or 18 9 a5ed xe:1 dH LVL0 61.0E 82 JeW Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is for every re Centerville MA 02632 3-26-19 required paw, CitytTom State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on'310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: 1500 Gal. Tank D Box and three chambers. Number of current residents: 2 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available (last 2 years usage (gpd)): 2017-32,000Gals 2018-39,000 G a l's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date 15insp.doc•rev.7/2812018 Title 5 Official Irspectlon Form:Subsurface Sewage Disposal System•Page 7 of 18 L a6ed Y2J dH 86:L0 660E K JeW Commonwealth of Massachusetts Title. 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P"j' l;f 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is required for every Centerville MA 02632 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont,) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 115.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq,ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of Information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7120,12018 Title 5 Oftial Inspection Form:Subsurface Sewage Disposal system-pages or 18 9 a5ed xed dH 81.:L0 ME 82 JeW Commonwealth of Massachusetts 9Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0— 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is Centerville required for every MA 02632 3-26-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the 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: 1999 Permit # 99- 184. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5, Building Sewer(locate on site plan): Depth below grade: 23" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting,evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. I5insp.doc-rev.7126!2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 6 a5ed xe� dH 8 6:L0 6 602 8Z JeW Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owner's Name Information is required for every Centerville MA 02632 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont,) 6. Septic Tank(locate on site plan): Depth below grade: 13" 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: 1500 Gal. Precast H- 10 Sludge depth: 2« Distance from top of sludge to bottom of outlet tee or baffle 28 1" Scum'thickness Distance from top of scum to top of outlet tee or baffle 8« Distance from bottom of scum to bottom of outlet tee or.baffle 17" How were dimensions determined? Asbuilt-TapeSlud a Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level.Tank and covers at 13" below grade. In and out tee's. No sign of leakage or over loading. t5insp.doc•rev.7/2 61201 8 Title 5 Oi6dal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 D6 a5ed xe: dH 86:LD 61.0Z 82 JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owners Name information is required for every Centerville MA 02632 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 151nsp doc rev.V262019 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 6 a5ed xezI dH 6 6:L0 6 602 8Z JeW 4'\ Commonwealth of Massachusetts uR Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is required For every Centerville MA 02632 3-26-19 page Cityrrown State Zip Code Date of inspection D. System Information (cost.) 8. Tight or Holding Tank(cunt.) 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.): 4 '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 011 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-18"below grade, Box is clean and solid w/no sign of over loading or solid carry over. t5insp.doc•rev.7128/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Z6 a5ed xe:1 dH 66:L0 660E 8Z JeW Commonwealth of Massachusetts 1P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owners Name information is required for every Centerville MA 02632 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. I 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: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovativetalternative system Type/name of technology: tSnsp.eoc•rev.M612018 Title 5 Official Inspection form:Subsurface Sewage Disposal System Page 13 of 18 £6 a5ed xe:1 dH 61,10 6 60Z 8Z JeW Commonwealth of Massachusetts Title 5 Official inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 510 Main Street Property Address J H R Wing LLC Owner Owner's Name information is required for every Centerville MA 02632 3-26-19 page. cltyrrown 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.): Leaching is three 500 Gal. dry well chamber's w/4'stone. Chamber's at 25"below grade. Chamber's are clean like new. 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.): 154nsp.doc•rev.7,2612018 Title 5 Official Inawddon Form:Subsurface Sewage Disposal System-Page 14 of 18 tq a5ed Y2J dH 66:L0 660Z R JeW Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information Is required for every Centerville MA 02632 3.26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 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.): Mnsp.doc-rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 15 of 18 �6 abed xe:1 dH 66:L0 660E R JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 510 Main Street VV)," Property Address JHR Wing LLC Owner Owners Name information Is required for every Centerville MA 02632 3-26-19 page. City/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: ® hand-sketch in the area below ❑ drawing attached separately 8 �'�A� 3� A �a= 36 (. 0 ao l 13.. 3 - 0 0 0 t5insp.doc•rev.MUM B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 or 16 96 a5ed xe� dH 66:L0 660E 8Z JeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 510 Main Street Property Address JHR Wing LLC Owner Owner's Name information is required for every Centerville MA 02632 3-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth toffiigh ground water: 2 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS Luell You must describe how you established the high ground water elevation: G W at 25'+ Bottom of chamber's at 5' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7l262018 Title 5 official hspection Form:Subsurface Sewage Disposal System-Page 17 of 18 L I. abed xeJ dH OZ:LO 6 L02 8Z JeW I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t� 510 Main Street Property Address J H R Wing LLC Owner Owner's Name information is required for every Centerville MA 02632 3-26-19 page. CityfTown 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 GRAD OoXa M C NAZI a E,f S D r 151nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 9 l, abed xeJ dH OLO 61.0E K JeW t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 510 Main St. 6� I 1M Property Address 1 Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name rab P.O.Box 763 Company Address Centerville - Ma. 02632 serum City/Town State Zip Code (508)428-4028 S 14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® ,Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -- C0 o DK U 1/03/2008 ` Inspector's Signature Date w rn The system inspector shall submit a copy of this inspection report to the Appro Ang 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. 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ aSubsurface Sewage Disposal System Form - Not for Voluntary Assessments M 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or"more system components as described in the "Conditional.Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. , Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please-explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed . 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 510 Main St. Property Address . Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction,is removed ND Explain: . r C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® 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 ❑ ® 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. 510 Main st.•12167 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. 0 ® 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 god to 15,000 god. 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. 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? t ® ❑ 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)] 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate'inspection required] ❑ Yes ® No Laundry system inspected? ® Yes' ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:7,000 g ( y g (gpd)): 2007:16,000' Sump pump? ❑ Yes ® No Last date of occupancy: 1/03/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 510 Main st.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 510 Main St. M Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information 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: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 510 Main st.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cone.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC, ❑ other(explain): Distance from private water supply well or suction line: 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): Depth below grade: 18"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: 1500 gallon Sludge depth: 4" I Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 510 Main st.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, . liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) x Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 2 outlet laterals with equal distribution.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 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 510 Main St. M Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: J Type: 0. leaching pits number: ® leaching chambers number: 3 ❑ 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.): Sandy sry soil.No signs of hydraulic failure.No ponding or damp soil. 510 Main st.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out J.(�J J J J J In 'A K r'y ♦ 7 - N O c� { 0 20 Feet Set Scale 1" = 20 I Aerial Photos Cn—rinh4 9MF_9M7 Tnu,n of Qn—cf6kin KAA All rinhte rconnn http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=207044&mapp... 1/8/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 510 Main St. Property Address Sandra Mercandetti Owner Owner's Name information is required for Centerville Ma. 02632 1/03/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of Chambers 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:Gaherty& Miller model 12/16/94 ground water elevations.USED:USGS Observation well data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 510 Main st.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF 1NE 1p� Regulatory Services BARNSTABLE ; Thomas F. Geiler, Director MASS. Public Health .Division TED►,M.�A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. r In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic _ System Inspector who conducted the inspection. 1, COMMONWEALTH OF MASSACBUSETTS Tt EXECUTIVE OXVICfE RONMENTAL AFFAIRS DEPARTMENT grbEr4vp Y�I ENTAL PROTECTION FCTOWN jual E® ARNSTABLE ,TITLE 5 _ HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION f Property Address: � - ' x/C/A'o-e_ A Owner's Name: 4 / Owner's Address: ;B 421 A AP - �+ Date of Inspection: ,iRCEL '` _, .. Name of Inspect '9 lease riot f T ; Company Name: Mailing Address: Telephone Number: 9 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _._--� Date: 3clw� 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. Notes and Comments ` ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 j r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION (continued) Property Address: _ e j �L Owner: L F /�20�Qj Date of Inspection Inspection Summary: Check A,B,C;D or E./ALWAYS complete.all of Section D A. 7stem 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 1.5.304 exist. Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: S 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,NNill.pass; Answer.yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined.'.'please explain. The septic tank is metal and.over 20 years old* or the septic tank(whether metal or not).is structurally- unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation-of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if.(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection.if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain:. 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: r .4 Owner: . Date of Inspection: 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. ]. System will pass unless Board of Health determines in accordance with 510 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property ress: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for,all inspections: Yes NoJ Backup of sewage into facility.or system.component due to overloaded or clogged SAS:or cesspool Dischargel 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.clooged SAS or cesspool, _ Liquid depth in cesspool is less than 6" below invert or available volume is less than./z day flow _�. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped 11 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. c/ Any portion of a cesspool or privy is within 50 feet of d.private water supply well. Any portion of a.cesspool or privy is less than 100.feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system.passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fro.m4hat facility and the:presence,of ammonia nitrogen.and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria (� are triggered. A.copy of the analysis must be attached to this.form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria.exist as described in 310 CMR 15303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E: Large.Systems: To be considered a large system the system must serve a facility with a design flow of 10;000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems.in addition to the criteria above) yes , no _ the system is.within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area I WPA)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: 4 Page 5 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: !Z4nE Z-& Date of Inspection: ZIZ462cs2z / �C Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes — Pumping,information was provided by the owner,occupant, or Board of Heaith /Were any of the system components pumped out in the previous two weeks ? -v4Ias 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? v Were all system components, excluding the SAS, located on site �7_ 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: Yes no / Existing information.For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEKINFORMATION Property Ad ress: /�C —/��cGRxzle /�- Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL. V Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 3 10 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current resident Does residence have a garbage grinder(yes or no): U Is laundry on a separate sewage system ( es or no): if yes separate rnspection required] Laundry system inspected y s.or no);: Seasonal use: (yes or no): Water meter readings, if/�a,9 ilable(last 2 years usage(gpd)):. U'Z 41ro (� 1� Sump pump(yes or no)Yt/4 / Last date of occupancy: G COMMERCIAL/INDUSTRIAL//960Y Type of establishment: Design flow,(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the ins ection(yes�or no): If yes, volume pumped: gallons;-How was qua titypumped determined? Reason for pumping: TTYP OF SYSTEM tic tank, distribution box,soili absorption system _Single cesspool _Overflow cesspool _Privy _Shared system (yes or no)(if yes;attach previous inspection records; if any) _Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval —Other(describe): A oxi e age of all components,date installed(if known) and source of information: 4 40- Were sewage odors detected when arriving at the site(yes or noc`): 6 Paee 7 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property ress: Owner: Date of Inspection:_ BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from priate v,ater.supply well orsuction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: . oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) / Dimensions: Sludge depth: Q Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 //- Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto 0 outlet tee or b ffle: How were dimensions determined: Comments(on pumping recommen ations, i et and outlet tee or baffle condition, structural integrity, liquid levels elated to outlet invert,evi ce of leakage,et ): i GREASE TRAP:/ jdklocate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: N Date of Inspection: TIGHT or HOLDING TANK/(tank must be pumped at time of inspection)(locate on-site plan) Depth below grader Material of construction: concrete metal : fiberglass_polyethylene other(explain);. Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: of present must be opened)(locate on site plan). Depth of liquid level above outlet invert: blpeel Comments(note if box is level and distribution to outletselual, any evidence of solids carryover,any evidence of . Ae age into or out of box,e .): 99tz&,AzLed a�)a &26�4 PUMP CHAMBER/_`° _ ,` locate on site plan): Pumps in working or/der(yes or no): Alarms in working order(yes or no): Comments(note condition.of pump chamber, condition of pumps and appurtenances,etc.):. 8 Page 9 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION(continued) Property ress: 24 V1, e'V .4 Owner- Date of Inspection. SOIL ABSORPTION SYSTEM (SAS (locate on site plan,excavation not required) If SAS not located explain why: Type Ching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, ?tc. / s CESSPOOL(cesspool /must be pumped as part of inspection)(]ocate 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIM (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.): 0 Page 10 of 1.1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property ress: C' � Owner: Date of Inspection: JdG SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including:ties to at least two permanent,reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the build ng. 1� � , ya►3 � o, i . 10 P - Page 1 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continue A fC! Property A ss: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) ✓ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 5 5 11 - ,,._,„s,:,-_..:�;;.:-..ate .itA'1•r: Permit ;t Number: -Dat e:Completed by: 01. _ 'r'l �PC'LI{\iD.�1t.�i ER _c %EI CUAAPU I ,i IGN "•a.��tn'�:dam i-`- Wit��'ir -.Site Location: Lot No. gi -,s; Owner: 111L Address: Ongh '.Contractor: ��' C�%�LS -ddress ' STEP 1 Measure depth to water table to nearest 1/1:0. t�. ..................................... ..................... ............. nonth/day/`/'ar �. ` STEP 2 Using Water-Level Rance Zone and Index reap locate . .: site a"nd det2rm.lne: �A Aapr n opate index well........... CWater-level range zone !� • Ij I S T cP 3 Using monthly report "Current i ! '-Afater Resources C'ondi'iion-," i I determine current'depth to i 6 ! �I water !eve! for InGe:: UV2il ...................... � ! •.... rilGnZn/Y9ar S l Ep 41' Usino !able of Water-level Adjustment5 I!( for index well (STEP 2. ), current depth to water level for index well (STEP EP 3), ! and wager-lees?'zone (STEP 28) . determine ,,eater-level adjustment STEP 5 Estimate depth to hiah.water by subtracting the water- level-adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ................................................................................................ .......... 'IcJF �.-- ;8f� lh�iIB!.;0!T;pU$?iQii ioiill, .- .. ..... "�.,,...... -....a........,l�r�•`1��--..._....._...._._.........,�_w......., ..._......W. ��.,. _.m�,,......,._....._......m �;:xa.w;�x::bJ::_,....,..._.:_,.... ,..... j how, AL ................_ TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE Cr�ri=r/irk= ASSESSOR'S MAP & LOT 207 -oyy INSTALLER'S NAME&PHONE NO. y 27-a sv i SEPTIC TANK CAPACITY /SDO LEACHING FACILITY: (type) Or:i 4-1_11:511r (size) _ 32 X NO.OF BEDROOMS BUILDER OR OWNER Ol+vl 10-e r k gq1,, T7'1 PERMITDATE: 1-/-! -99 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by. r L � AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION S-/0 SEWAGE# VILLAGE Cv>>i='rVi//- ASSESSOR'S MAP&L INSTALLER'S NAME&PHONE NO. 5'97-03S'Q SEPTIC TANK CAPACITY /.SbO LEACHING FACILITY: (type) _3-S"oo Ga/, Qr_ GCii_=// (Size) NO.OF BEDROOMS 5' BUILDER OR OWNER v 1 PERMIT DATE:_. y- -9 9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Furnished by u�tit a�- rroN�' AI h Fd 5-- http://issgl/intranet/propdata/prebuilt.aspx?mappar=207044&seq=1 2/4/2009 TOWN OF BARNSTABLE iNd. TION rX0 �Iw.a Sr SEWAGE # AGE Cr_�r�Ti=rVi//r- ASSESSOR'S MAP & LOT 207 -0`1q ALLER'S NAME&PHONE NO. y77-03y9' IC TANK CAPACITY /S00 HING FACILITY: (type) -S"oo�on/ Dry uir?/6 (size) I.2 X l! F BEDROOMS BUILDER OR OWNER rri' PERMITDATE: jCOMPLIANCE DATE: /Y- 99 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 s . y �, M � $ s �tih ,��, ,�y�. No. �!` 1 � �,1 Fee THE COMMONWEALTH OF MASSACHUSETTS `'` Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Mizpogar *potem Cow6truction Permit Application for a Permit to Construct( )Repair(4%�pgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. S'ld /-0;w/!1 S r Owner's Name,Address and Tel. `f el o- 1196— Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Jos cpl 0-c 0op'-0-5 J�� i 0_ / v ��• r��S ✓/�%/ Sly Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soil Sail Nature of�iepairs or Alterations(Answer when applicable) �%1(l Sl'i`/O Gl:SSpU 0/ ay,,711 ��1-"�17 %9t ZIT - T Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed !tee�l'�i %'�o �Si��miriv� Date q-/5- 7V Application Approved by Date Application Disapproved for the ollowmg reasons Permit No. 9 3 Date Issued _•_• -_ - •+r...= -_. .__..,...... �_— �� _ �—— r � ..._ of_ . No. C .. Fee .15��i } THE COM g '4-•- '- Entered in computer: MONWEALTH OF MASSACHUSETTS Yes PUBLIC.HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS -� Zipplication for �Bizpogal *p5tem Construction Permit Application for a Permit-to Construct( )Repair(4ow)'Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address of Lot No. �j0 1'/9q/y/ s'r Owner's Name,Address and Tel.No. Assessor's Map/Parcel /%Hr�. ?-V///I'" iom,,l We,,-6 N4 444 7r, 207 Oy v /= Installer's Name,Address,and Tel.No. 41r/rf_03 q9 Designer's Name,Address and Tel.No. ✓os�p� D-c 00--1-115 Type of Building: Dwelling No.of Bedrooms tom/ _ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs-or Alterations(Answer when applicable)/ ru/lT !! 4 kl Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed i ��49; Me,41. - Date 4/-/.3- Application Approved by Date �J- Application Disapproved for the RIOWIA reasons Permit No. ,`�9 ! Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( 4.)-Upgraded( ) Abandoned( )by Ai e 424 le at c!/p ��_5� % ,, ,,-, �,%/i— has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated , Installer /, � 42, W.4 Q92 S Designer .Jose ol, 12,, I3'y�d►ro,S' "�t j �J The issuance of this permit shall not be construed as a guarantee that the sys,ill function as designed.14, C� �I � Date AInspector � �`f` � V r� No.... ( ! Fee THE COMMONWEALTH OF MASSACHUSETTS O7 Oy'Y r PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mizpozar *p!gtem Cow6truction Permit Permission is hereby granted to Construct( )Repair( 6.-1 1pgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 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: Approved by i!669 y - a NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNER PLkNS) I, ,Joa-caul, V, &oeej , hereby certify that the application for disposal works construction permit signed by me dated y^ / - g concerning the property located at r>d �.��h Sr' ��h��. r✓�/% _ meets all of the following criteria: • The failed system is connected to a residential dwelling only. Them are no cocr.merciai or business uses associated with the dwelling. � The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. /,fThere are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system �Th e-is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will n—t be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater fable 1!sing the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of'the proposed leaching facility will not be located less than fourteen(14) feet above the maximurn adjusted groundwater table elevation, Please complete the following: i1 A) Top of Ground Surface Elevation(using GIS information) _ © B) G.W. Elevation +the MAX. High G.W. Adjustitient ,I,G DIFFERENCE BETWEEN A and B /�. SIGNED DATE: [Sketch proposed plan of system on back]. 9;he&M folder.cm _ Q I Vv O OA b d v A V J � W f r yatc!�.:It 'i, �Itln. ��• ` Ow * y •Yi` uyeeyp: J 7 * a n tr 4r;� i r. 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N/GX C�I�NI:t D per! E 3 OF5 DANIELLE ENTERPRISES SAWWICH, NIA 02563 Y Da/d�cev�,� 508-280-9896 DAre, ra MAY '7n1n etV15/0N. N EXISTING LAYOUT REMOVE REMOVE DOOR WINDOW 4. Ee sink Water Heater Lr = RECONFIGUR NEW KITCHEN CABINETS BATHROOM PARTITIONS NOTE: KITCHEN REPLACEMENT WINDOWS TO BE Zia INSTALLED IN THE EXISTING OPENINGS UNLESS OTHERWISE REMOVE WALL REMOVE WALLS NOTED � DEN Laminate Flooring REMO WALL Nc� BEDROOM o N 26C8 LIVING AREA NZ 4 REMOVE DOOR Laminate Flooring REMOVE 1 WINDOW g RELOCATE 2 WINDOWS f% PROPOSED INTERIOR CHANGES GENFEWIL—Lf, I"Its � 10 l.HA1WES STREET if}l�; �/�'r=l'�Qrr P�1G�. 4 OF 5 NICK G11WrF ANrf D � E DANIELLE ENTERPRISES SANDWICH, MA 02563 Daid/e 508-280-9896 1a MAY -71--)In P V1S1oN; �i PROPOSED LAYOUT REMOVE DOOR REMOVE 1 WINDOW LL1 O VANI7Y3G Tile NEW CABINETS QUEEN BED BATH NEW WALL P e n (\(v\ KITCHEN NEW WALL �9 Laminate Flooring NEW -O MASTER BEDROOM CLOSET N o carpet LIVING AREA t73O REMOVE DOOR Laminate Flooring REMOVE 1 WINDOW RELOCATE 2 WINDOWS r PROPOSED INTERIOR CHANGES KtFC1-1fN1PA7 /IPE1100ft- �5/0 /IA/N STPEET 10 CHARLES STREET , : GAGE; D,C'1tWN DY; DANIELLE ENTER.PRISES 5 OF 5 D � ESANDWICH, MA 02563 NICK CIt F1ffP wf paldree 508-280-9896 C)Are; ,a r i av �n�n PEV15/0k 1