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HomeMy WebLinkAbout0072 MERIDETH WAY - Health 72 Merideth Way Centerville P 147.104 salmado I k 4 1 UPC '2543 NOSROR a �a .�avr�sca@ 1/ti l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is Centerville MA 02632 April 25, 2014 required for every P 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:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return key. Name of Inspector ,.. -�'— Eco-Tech Environmental r� Company Name „s - P.O. Box 1265 Company Address � West Chatham MA �402669 *-1 City/Town State Zip Code ,rv" '.r") 508 364-0894 1328 Telephone Number License Number %l 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: of�s ® Passes VAya�A�' s9�� Conditionally Passes ❑ Fails DAIM yam ❑ Needs Further t�NAN�WR al Approving Authority No.1328 �sr ppRov� April 25, 2014 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-3113 Title 5 Official Inspecti my.Subsurface Sewage Disposal System•Page 1 of 17 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. .•-';gig��1���" The septic tank is metal and over 20 years old;or tlie`septie,tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration.or tank i'il"re is imminent. System will pass inspection if the existing tank is replaced with;aacomplyIng Sept c:tank as approved by the Board of Health. t,-� t *A metal septic tank will pass inspection If It'ls,structurally;-sound, not leaking and if a Certificate of Compliance indicating that the tank is less than*"20 y a s•old:, s available. ❑ Y ❑ N ❑ ND (Explain below): l5ins•3/13 + 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 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is Centerville MA 02632 April 25, 2014 required for every p 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is Centerville MA 02632 Aril 25, 2014 required for every P 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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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? ® Y p 9 ❑ 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 gpd 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 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System was installed by R & R Excavating in 1984. Number of current residents: 2 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 238 gpd 9 ( Y 9 (gP ))� Detail: 2012: 98,000 gallons 2013: 76,000 gallons 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 W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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: owner 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) 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): l5ins-3/13 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 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is Centerville MA 02632 Aril 25, 2014 required for every p 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: 29+ years. Disposal Works Permit for new system issued 8/1/1984 (Permit#84-538) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. 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: 8.5 x 5 x 6-1000 gallon Sludge depth: 4 in t5ins-3/13 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 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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 30 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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 at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box appears structurally sound with no evidence of leakage in or out. Some solids in sump. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leaching gallery. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is Centerville MA 02632 Aril 25 2014 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leaching gallery. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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•3/13 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 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is Centerville MA 02632 Aril 25, 2014 required for every _ p 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 THIS SKETCH IS L�OCA T§O BEST VIEWED IN 11V COLOR FORMAT -OF SEPTIC COMPONENTS -DISTANCES IN DECIMAL FEET A 8 1 37 33 2 41 39 3 62 29 EXISTING DWELLING ING OV 72 B A 1 FLOW DIFFUSSOR SYSTEM n IS H-20 RATED - SEE 1000 GALLON ,� ADDENDUM ON PAGE 18 SEPTIC TANK o n m DISTRIBUTION 2❑ p p O rnBOX LEACHING \ ;. GALLERY rn i n .o 508 364-0894 MERIDETH WAY 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 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is required for every Centerville MA 02632 April 25, 2014 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: 9/22/2009 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Barnstable GIS Department records ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 6 feet above the bottom of a test pit in which no groundwater was encountered. Town of Barnstable GIS Department records indicate that the property is over 15 feet above nearby Lumbert Pond. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Merideth Way Assessor's Map 147 Parcel 104 Property Address Erlmest and Janice Burns Owner Owner's Name information is Centerville MA 02632 Aril 25 2014 required for every p 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 GEOHYDROLOGICAL PROFILE - NOT TO SCALE z Q J a 2 CA W PRECAST o FLOW z DIFFUSSOR BOTTOM OF a LEACHING � PER DESIGN � PLAN LEACHING IS ABOVE HIGH GROUNDWATER +• O ,6 NO GROUNDWATER ENCOUNTERED t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 FD 4 X 8-D FLOWDIFFUSOR® .n. �dalPad0\,A +0 T:+IP 5 14wd"OK repw f of _72- MEREDITH WAS{ THE BEARING POWERS OF SOIL CENrE2V� �-L� M /� SUPPORTING ANY STRUCTURE SHOULD BE DETERMINED AND EQUATED TO THE APPLIED R pri 0 LOADS TO CALCULATE THE BEARING AREA REQUIRED. I i I 1 ' , 1 I I 4'-0" I I I , I i I L - _ t• 1 CLEAN OUT&INSPECTION COVER PLAN VIEW (05 E= o ®1 I-0.I (30)2'x 572"OPENINGS� t KNOCKOUTS FOR BED INSTALLATION FRONT VIEW SIDE VIEW �.. 4._7 B.. B:. 2.,... 1.8..SLOTS 2" % -- - - - ---- � 1, 'g•• p p 11'/2"FLOW LINE s SECTION A-A SECTION 13-13 BEARING AREA PER CHAMBER — 4.18 S.F. SPECIFICATIONS • Concrete Minimum Strength; 4,000 P.S.I. Q 28 days �DD V M • Steel Reinforcement; ASTM A-615-75, Grade 60 PG�E • Design Loading: AASHO - HS-20 'S 24 PARCEL, ECOJECH LOT Environmental www.eco-tech.us THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SIJBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 72 Merldith Wav Centerville Owner's Namc: Janice Burns Owner's Address: 40 Pequot Road Mashpec. MA 02649 RECEIVED Date of Inspection: September 14. 2004 Name of Inspector: (Please Print) David D. Coutthanowr. R.S. SEP 16 2004 Company Namc: Eco-Tech Environmental Mailing Address: 43 Triangle Circle TOWN OF BARNSTABLE Sandwich. MA 02563 HEALTH DEPT. Telephone Number: (508) 304-0894 CERTIFICATION STATEMENT- I certify that 1 have personally inspected the sewage disposal system at this Address and that the information reported below is Iruc.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(311) CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature rAmlls-- �� 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 o\\ner and copies sent to the buyer, if applicable,and the approving authority NOTES AND COMMENTS. /nspec2or's Note==> .1 septic sv—Stem is deente d to pass this Real Eslnie 7rrnn.s/er Inspection if it does not trigger am of fhe failure criterirr listed helow. The septic s'vs/cm has been eralualecl occordii,g to the conditiotr.c observed on the elm-it woo in.�pectec% No estininte or<(unrnrnee ol'.,yslein for{L'evily is marle or implies!by a passing determination. ****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 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Merldith Way Lenten ille Owner: Janice Burns Date of Inspection: September 14. 2004 INSPECTION SUMMARY: Check A, B,C, D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: BJ 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,or ND). in the_for the following statements. If"not determined" please explain. The septic tank is metal and over 20\,cars old* or the septic lank(whether metal or not), is structurally unsound,exhibits substantial infiltration or exliltration. 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 Icaking and if a Certificate of Compliance indicating that the tank is less than 20\,cars old is available. ND explain: Observation or sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or duc to it broken. settled or uneven distribution box. The system will pass inspection if(with approval of Board of Health). broken pipc(s)arc replaced obstruction is removed distribution box is leveled or replaced. ND explain The sysicin required pumping more than four times a year duc to broken or obstn►cted pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)arc 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: 72 Merldith Way Centerville Owner: Janice Burns Date of Inspection: September 14. 2004 C) Firilher Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to dctennine if the system is failing to protect public health. safety and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(1))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 Nvater Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System w i I I 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis. performed by 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 anunonia nitrogen and nitralc nitrogen is equal to or less than 5 ppnt. provided that no other failure criteria are trigg ered. A copy of the analysis inust be attached to this form 3) OTHER 3 i Page=4 of I I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 72 Mcrldith Way Ccnta-villc Owner: Janice Burns Date of Inspection: September 14. 2004 D) System Failure Criteria applicable to all systems: You must indicate either"yes" or "no" to each of the following for all inspections: I have determined that one or more of the lollo%\ing failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to detenuine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or.surface waters due to an overloaded or clogged SAS or cesspool. . X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than G" below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstnrcted pipe(s).Number of times pumped X Any portion of the SAS.cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone l of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 51) feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed by a DEP certified laboratory. for coliform bacteria and volatile organic compounds indicates that the well is free front 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) No (Yes/No)The system rails. 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 Nyhat will be necessary to correct the failure. E)Large Systems: To be considered a large system the system must set-ve a facility with a design flow of 141,4100 gpd to 15,000 gPtl 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 wilhin 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. 4 Page i of I I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 Merldith Way Centerville Owner: Janice Burns Date of Inspection: September 14. 2004 Check if the following have been clone: You must indicate either"Yes" or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner. occupant or Board of Health. N Were any of the system components pumped out in the last two\veeks'? Y _ Has the system received normal flows in the previous two week period'? N Have large volumes of water been introduced to the system recently or as part of this inspection'? Y _ Were as built plans of the system obtained and examined'?(If they were not available as N/A) Y _ Was the facility or d\%clling inspected for signs of sewage back-up'? Y _ Was the site inspected for signs of breakout'? including Y _ Were all system components.exeaud+aag the SAS. located on site'? Y _ Were the septic tank manholes uncovered. opened. and the interior of the septic tank inspected for the condition of the baffles or tees. material of construction.dimensions.depth of liquid, depth of sludge and depth of scum.'? Y _ Was the facility owner(and occupants. if different from owner)provided with information on the proper maintenance of subsurface disposal systems' For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The sire and location of the Soil Absorption System(SAS)on the site has been detennined,bascd on: Y _ Existing information. For example. Plan at the Board of Health. Y _ Determined in the field (if any of the failure criteria related to part C is at issue,approximation of distvace is unacceptable) 1310 CMR IS.02(3)(b)� 5 I Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 Merldith Way Centerville Owner: Janice Burns Date of Inspection: September 14. 2004 FLOW CONDITIONS RESIDENTIAL 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 gl� Number of current residents I Does the residence have a garbage grinder(yes or no): no Is laundry on a separate se\\age system (yes or no): no :( If yes. separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings. if available(last two year's usage(gpd): 392 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/IN DUSTRIAL: Type of establishment: Design (low(based on 3 Ill CM 15.,203):: gpd Basis of design flow(scars/persons/sgft/ctc.): Grcase 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 availablc: Last date of occupancy/use:_ OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System not pumped in recent past Owner Was system punnped as part of the inspection: (yes or no) No If yes. volumc pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: X Septic tank. distribution box. soil absorption system Single cesspool Overflow cesspool Privy Shared systenn (yes or no) ( if yes. attach prey ions inspection records. if any) Innovative/Alternate technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Mach a copy of the DEP approval Other(describe) APPROXIMATE AGE of all con,nponents. date installed(if known)and source of information: Age: 20+\cars Certificate of Compliance issued 9/20/8 4 (BOH permit #94-583) Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of I I OFFICIAL INSPECTION FORNI_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Merldith Way Centerville Owner: Janice Burns Date of Inspection: September 14. 2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Mata-ial of construction:_casl iron X 40 PVC_other(explain) Distance from private N\aler supple we11 or suction tine 20+ Comments: (on condition of joints. venting. evidence of leakage. etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK: Yes (locate.on site plan) Depth below gradc: 15 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal. list age_ Is age confirmed by Certificate of Compliance_(yes or no): (attach a copy of certificate) Dimensions: 8.5 ft x 5 fl x i ft (1000 gallon) Sludge depth: 9 in Distance from top of sludge to bottom of outlet Ice or baffle: 25 in Scu►n thickness: 3 in Distance from top of scum to top of outicl tee or baffle: 9 in Distance from bottom of scum to bottom of outlet Icc or baflle: 12 in Hoy dimensions\\erc determined: Probe to top of lank Comments: (on pumping recommendations. inlet and outlet tee or baffle condition. stnrctural integrity, liquid levels as related to outlet invert. evidence of leakage. etc.): Pumping recommended at this time and maintenance pumping is recommended every 2 years. Liquid level at outlet invert.Tank and tees appear structurally sound and functioning;as intended. No evidence of leakage in or out GREASE TRAP: none (locate on site plan) Depth below gradc: Material of construction: _concrete_metal_ fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top ol'scum to top of outlet [cc or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: (on pumping reconuuendations. inlet and outlet lee or baffle condition. stnrctural integrity, liquid levels as related to outlet invert. evidence of leakage. etc.): 7 Page x of 1 I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Merldith Wav Centerville Owner: Janice Burns Date of Inspection: September 14. 2004 TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete_metal _fiberglass_polycilrylene_other(explain) Dimensions: Capacity: gallons Design flow: _gallons/day Alarm present(yes or no):_ Alarm level: _ Alarm in working order()cs or no):_ Date of last pumping: Comments:(condition of inlet tee. condition of alarm and float switches. e(c.) DISTRIBUTION BOX: Yes (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: at outlet invert Conuncnts:(note if box is level and distribution to outlets is equal.any evidence of solids carryover,any evidence of leakage into or out of box. etc.) D-box appears structurally sound with no evidence of leakage in or out. Effluent level at outlet invert. Some solids in tank. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Conuuents(note condition of pump chamber. condition of pumps and appurtenances, etc.): x Page 9 of I I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Merldith Way Centerville Owner: Janice Burns Date of Inspection: September 14 2004 SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan;excavation not required) If SAS not located. explain why: Type: _leaching pits. number_ _leaching chambers. number X leaching galleries. number I _leaching trenches. number. length _leaching fields. number. dimensions _overflow cesspool. number _innovalivc/alternate syslcn► Typchminc of Technology Comments: (note condition of soil. signs of hydraulic failure. level of ponding,damp soil,condition of vegetation,etc.) Soils above leaching;gallery appeared unsaturated. No evidence of surface ponding. breakout. lush vegetation.or other evidence of hydraulic failure was observed. An observation hole was dug into leaching gallery stone which showed no effluent contact staining. No standing effluent was observed in the top I foot of stone. CESSPOOLS: none (cesspool must be pumped at lime of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids lave►': Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inllo\%(ycs or no): Comments: (note condition of soil. signs of hydraulic failure. level of ponding,condition of vegetation. e(c.): PRIVY: none (locate on site plan) Materials of consmiclion: Dimensions:_ Depth of solids: Conunents(note condition of soil. signs of hydraulic failure. level of ponding.condition of vegetation, etc.): 9 Page I0 of I I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Merldith Way Centerville Owner: Janice Burns Date of Inspection: September 1.4. 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the se\uge disposal system including tics to at least two permanent reference lanchnarks or benchmarks. Locate all wells within 100'(Locate NNhere public water supply enters the building) LOCATIONS A B 1 37 ft 33 ft 2 41 ft 39 ft EXISTING 3 62 ft 29 ft DWELLING B A W Z 1 J O SEPTIC w TANK o 3 i 2 LEACHING 1 ❑ D-BOX GALLERY MERIDETH WAY NOT TO SCALE 10 r Page I I of I I ' OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 72 Merldith Way Centerville Owner: Janice Burns Date of Inspection: September 14. 2004 SITE EXAM Slope Surface water Check Cellar Shallow N%clls Estimated Depth to ground%Hater: It)+ feet Please indicate(check) all methods used to determine high ground water elevation: X Obtained from system design plans on record - If checked. date of design plan reviewed 8/1/84 Observed Site (abutting properly/observation hole%\ithin 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators. installers-attach documentation) Accessed USGS database You must describe hog\. you established the high ground water elevation. Approved design plan on file\\ith Board of Health shoes bottom of systcm to be G feet above the bottom of a test pit in which no eater was encountered. Applying a groundwater adjustment of 3.5 feel (Index well SDW-252 Zone C. March 23. 19X4 reading=48.5)demonstrates that the bottom of the SAS is above adjusted high groundwater. II Orv CATION ��� �z zSEWAGE PERMIT NO. ILLAGE C QAITCA j INSTALLER'S NAME i ADDRESS i 90(ie2 i go, --go l P Ro i B U I L D E R OR OWNER C.�fAi, R>el4 j1 DATE PERMIT ISSUED (aaO DATE COMPLIANCE ISSUED ' a t 33 . 4,- 4 r No...... y ...3_ Ymim .5.. ................... 2, T E COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH .................... .. .............OF................................................. Appliratinn for 11iipusal Workg Tumitrnrtiun ramif Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: fir"------ -------------------------------------------- ---- cation•Address or Lot No. ............................................ Owner Addr Wf .......... .elUiC ----••-•-•------- Installer Address Type of Building Size Lot._&f_j0_P_4------Sq. feet Dwelling—No. of Bedrooms...............3.........................Expansion Attic ( ) Garbage Grinder (Al/ 04 Other=Type of BuildingsNo. of persons......Z.. 97 ( ) Cafeteria owers dOther fixtures .-S w Design Flow........L.`. p._9.........'____...gallons per person per day. Total daily flow.-_--. .a........................gallons. 9 Septic Tank Disposal Trench—' Liquid No capacity-......idthns Length Total Lengthidth.............. Total leaching area-•Depth.._--..sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed ?1e....................•........ Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---_----_____-__-------. rs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' •--•-•------•-•--•--•--------•..........-•--------------•----•-•••---•-•••------._...-•-----••••.....----••..._..----•-•.......--------•...------.......-•--- 0 Description of Soil...............•............................-........................................................................................................................... x w UNature 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 TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by theboard of health. Signed /�• --------•-- -----••-- .................... `. r -�1)ate Application Approved By-•........--- T..... --.................................... ••--...... - 1 c�D e Application Disapproved for the following reasons:---•-----------------------•------------------------------------------------•--------------------------........_ ............................•--.....-••-•-•........•-------•-•--•----•--•--••----.•...-----•-••-----•-•••I-•--••---...._........._----•-•----•--_...----•---••••-------------•-------------•----•-••-•--- Date PermitNo......................................................... Issued....................................................... __�Date----- �„.., No.....jp� �. F�$... ................... rTHE COMMONWEALTH OF MASSACHUSETTS ` BOAR® Off` HEALTH 1 ...................` OF.................... Appliration for Disposal Vja&s Tonstrurtion jhrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .. ---••---------------•---------------•---- � ---------....................-----•-- ooation-Address --- ' f -`..... — ------------ 411 t. .N.c' ,?' t✓,lJj:S. Owner Addr s Installer Address U Type of Building Size Lot.l ' .11: G.......Sq. feet Dwelling—No. of Bedrooms............... ......................Expansion Attic ( Garbage Grinder 4/() aOther—Type of Building !4? __. 1���';1�No. of persons.....'>__6!?7_H_ howers ( ) — Cafeteria ( ) � Other fixtures ------------------------------------------------------�-------•---------...-----------------------------------------------••---i-------•-----------•- W Design Flow....... ..................gallons per,person per day. Total daily flow__.. -9........................ WSeptic Tank—Liquid capacrt ti...°_gallons Length................ Width................ Diameter---------.:_ .. Depth................ x Disposal Trench—No.................'�:..,Widt'h.....__........._.. Total Length.................... Total leaching area_-_--___---- _..sq. ft. Seepage Pit No--------------------- Diameter_............ Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box Dosing..' osin tank � Percolation Test Results Performed b ..f !'+ 1 -.�» ...VZ ...................•........_ Y Date Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0-4 f14, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... P4 -•••••-••-••......------•••-•-•.....-••••-•--•-•--••--•----------------..................................................................................... 0 Description of Soil................................................................................. =...........................................................=....................... W V ....•-•--•----••••-•------••••---•-•-••--•---------•-•--•-•-•---------••------••---•.....-------•-•------•--•---------•••--•••-••------••--•••••-•--•...-----•--•-----•--•-------------••-•------•-.... W UNature of Repairs or Alterations—Answer when applicable-------------------1..........................................:................................. ---------------------------•---•------......----------------------------------------------...------------------------------------------------------------------------------------------•------•--.-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.... .. . .. ...-------- •.................. ................................ � ate Application Approved By............... ....., r! .._...... ................. ----------4/0 D to Application Disapproved for the following reasons:............................................................................................................... ----------------------•--.....-----•----...---------...------------•-•-----------•--•------•-------------•-----------•-••-•-----•-•---••----.--•----•-••--••---•--•••-•-------••...•-----•---•....------ Date PermitNo.......................................................- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF{ HEALTH ..........................................OF........................................................... (Intifirate of TontpfiFanrr mw THIS IS TOzeEYTIFY�That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-------------------------- -......,�- ------------------------------------------ .----------- -------------------------------------•------------ nstall at----.............. ----- - ✓�"� has been installed in accordance with the provisions of TITLE p5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------- ?.. ".. "'..... dated_.............................................. THE ISS C OF THIS CERTIFICATE SHALL NOT BE CONSTRUI AS A GUTARANTEE;THAT THE SYSTER+1 F Y TION SATISFACTORY. DATE.... ._..... --•-------••........................................•.......... Inspector = ----------------------------------------------------------------------.----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No... ��.'. ...........................................OF......------.........----•----...---._...----...-------•----•-:...... ............ FEE..., '............. 'Disposal nr S #rnr#ion prrutit ... . Permission is hereby granted -------------------------------------------------•----------•••-•-........................ to Construct (I I or Repair ( ) an Individual .Sewage Disposal System at No. - B a4 treet as shown on the application for Disposal Works Construction Permit No................ ... Dated................................._........ / B and of FIealth .......................... DATE--------------•-••. {= ,�� ----------...................•............ FORM 1255 A. M. SULKIN, INC., BOSTON - 'D aTA .. .S IN6l..E . (.F.wi 3 8meoo,Gt� .., .. . . . .. . .:._'.. .. .... 1 4DO.GG� --- " , .,..•. . 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