Loading...
HomeMy WebLinkAbout0013 NAUSET LANE - Health 13 Nauset Lane Centerville P A = 170.. 055 Om. ord.. NO. 1521/3 ORA ;►�� 10% r' V �`s� B P e 5 _ � _� � �_ � __� � ��� �--�_ ��..« _.— .ram� _ � �� � _ �� �� � _ _ —. �_ �� � �� -�..—_ _ � d �� Commonwealth of Massachusetts �-51-0-U - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 13 Nauset Lane Property Address Kathleen Connolly Owner Owners Name information is required for every Centerville Ma 02632 6/23/2017 C.D page. City/Town State Zip Code Date of Inspection -' Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information S'� /aqa�- filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection r� Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the I Approving Authority 6/23/2017 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 Inspection Form:Subsurface sewage Disposal System»Page 1 of 17 ,C a�� VS ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 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 dwelling located at 13 Nauset Lane Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 4 Infiltrators. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i •a t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is Centerville Ma 02632 6/23/2017 required for every page. Cityfrown 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 G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 13 Nauset Lane Property Address Kathleen.Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No 0 ® 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 m 9 q , pp provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] 11 ® 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 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information.For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a r 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 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-3113 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 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is Centerville Ma 02632 6/23/2017 required for every page. Cityfrown 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: 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 2001 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1.5 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 gallons Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 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 was pumped at time of inspection and should be done every 2 years after for proper maintenance. Tank was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t g Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): i Depth below grade: i 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 ,Raw. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found in good condition, no rot, water level was even with outlet invert. 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 v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ 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.): s.a.s. was not located but no signs were present that would indicate previous hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. Cityrrown 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 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. Cityrrown 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 4 i FO 2 Ai 32. j2 5D �► h3.3b Mrvs•3113 Title 5 Official moo Form:SuWwiaos Sewap Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M 13 Nauset Lane Property Address Kathleen Connolly Owner Owner's Name information is required for every Centerville Ma 02632 6/23/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. 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 M 13 Nauset Lane Property Address Kathleen Connolly Owner Owners Name information is required for every Centerville Ma 02632 6/23/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•3113 Title 5 Official Inspection Form:Subsurface p Sewage Disposal System•Page 17 of 17 7ST_ z�� T , 7 = FDEC IVED .AP � FARCE,. K �_ 3 2004 TOWN OF BARNSTABLE DATE 11 1 2 61 D 4 HEALTH UEPT. PROPERTY ,ADPRESS 13 Nauhe.t Lane_ Cent eavi e ee, Na. 02632 On the above d6te,'the;.7®eptic system at the address above was Inspected. This system consists of the following:. 1. 1-1500 gai.Qon hepi_ic tank. 'dizi-a.igut.ion gox., 3. 3050 .in)eiet/zato/zz., q Based on inspection, I certify the following conditions: 4.7h:iz iz a t.itie Zive 3ept.ic zyztem. 5. The zep; :i.c zyztem .ih .in R.zopea woak.ing oadea at th pa nt t.ime.. SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc Address: P. O. Box 66' ' Centerville, Mass 02632 Phone: 508-775.3338 or 508-775-6412 jo%pH P. MACOMBER & SON,: INC:. Tanks-Cesspools-Leachflelds Pumped ,&•.Installed Town Sewer Connections P.O. Box 65 Centerville, MA.02632-0066 775.3333 . 7.75.6412. COMMONWEALTH OF MASSACHUSETTS EXECUTra OFFICE OF ENVIR(r'NMENTAL AFFAIRS d DEPARTMENT'OF'9NVII2,QINNIENTA3.,pROTUTION Y y� TITLE 5 OFFICIAL INSPECTION FORM—NQT;FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: 13 N a u e G ariy/e Owner's Name ff n ,4 f o n Ca e a n41 P� Owner's Address: C n m n Date of Inspection: i / 6/n 4 Name of Inspector: (please print)!2 o&eat I a Pi i n Company Name: / Macom&e2 Mailing Address: Pax 'AA Cen eavi e, N a� ,-02632 Telephone Number: 5 0-8-7 7 :3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and thatthe.information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my . . ' e sewage disposal osa 1 systems.I am a DEP and maintenance of on sit g p y training and experience in the proper function a g P approved system inspector pursuant to�Section.15:340.0'f Title 5(310 CMR,I5:a00). The system. _ Passes Conditionally Passes Needs urther Evaluation.by the Local Approving Authority 'Is Inspector's Signatore: Dater The system inspector shall submit a copy of this inspection reporrto the.Approving Authority.(Board of Health or 0,000 DEP)within 30 days of completing this inspection.If the system:is.a.shared system or has a design flow of 1 f the 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 torthe system owmi and copies sentto the buyer,if appticabte,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 tiube.This inspection does not address how the system will perform in the future under.the same or different conditions of use. ,r:+,e C TnenP/tt;nn Rnrm 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION(continued) Property Address: 73 N a u z e t Lane rvnfon»,;1/Ooi Mri Owner: A(1i ;6 t¢1't�1L gob 0.B Date of Inspection: y 9 f 2 61 n i Inspection S.ammary: .ChEek A•.B;C;D or.lE/ALWiAY�S complete<all of Section.D A. System Passes: n 0 I have not found any information which indicates'thaf any of the failure criteria described in 310 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: } B. System Conditionally Passes: no One or more system components as described in.the"Conditional:Pass":section-.need to be replaced-or repaired.The system,upon completion of 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. R O The septic tank is metal and,aver 20 years old*or the septic-tank(w:hether metal.or not)is;structurally unsound,exhibits substantial,infiltration or exfiltration.or tank.failure:iS:iniinent: System will pass inspection if the existing tank is replaced with'a complying septic tank.as-Apprvved 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: no. 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.replaeed ND explain: n o 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: P4ge 3 of 11 0"ICIAL I1 P-ECTION FORM-N©T YS�'E INSPECTION FORM TS SUBg1 WArCE SEWAGE D.ISROS*L PART A . . •C)CRT-MCAMON•(6oritinited) Property Address: 13 Nau se;t Lane -- Owner:. Kai s en Olte" 2e Date of Inspections C. Further Evaluation-is Requited by the Board of Health: no Conditions.exist whichrequire fiuther..eualuativn•by.the Boar'd:of-Health;in order.to: tterniine,if-the system is failing to protect public-health,.safety or the environment, )(b) 1. System will pass rinless board ofHealth determinesklb agaordance with 310-CMR 15:303.(1 that the system Is.not fun-ctiontttg ltt.a•mapper which=w111•protect public health,safety. NO•tbe..environment: n o Cesspool or privy is-within,50 feet of asurface water n o 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 Af any),dkiormines that the system is functioning in a manner that proteets the:public Health,safety and environment'. n o The system has a septic.tank and soil absotption'system•(SA•S).:and the SAS is within 100 fe.etof a surface.water supply or-tributary to a.surface water supply. n o The system-has•a.septic lank and SAS and the:SAS is--within a Zone 1 of.a public watensupply. n o The system has a septic tank and,SAS and the SAS is within:50 feet of a private water.supply well. n o The system has a septic tank and SAS and the-SAS is less than 100 feet.but 50 feet ormiore fiorb 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 d nitrate nitrogen is equal to or.less than 5.ppm,provided that no-other the presence of ammonia nitrogen an failure`.crfteria are triggered.'A copy of the analysis must be attached to-this form. 3. Other: Page 4 of 11 OFFICIAL••INSPEET10N FORM-NOT'FOR VOLUNTARY ASSESSMENTS SUBBSURFACE.SEWAGE DISPOSAM SYSTEM.INSPECTION.FORM PART A CERTIFICATION(continued) Property Address: 13 Nau,3et Lane K/ti,6t en /te OT e > Owner: Date of inspection: f 17 2 6/Q 4 D. System Failure Criteria applicable to all systems:. You must indicate."yes"-or"no"to.each.of-the:fpllowiIig,for al_I inspections: . Yes No _ x Backup.of se%viige:into-fat4Uty�r system component due.o overloaded.or clogged SAS..or.cesspool _ .x ' Discharge:or-ponding of effluent to the.surface bfther.ground pr...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.6"below invert or availabi�volume is less than'A day flow _ x Required pumping more-than.4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped x Any portion of.the SAS;cesspool or privy is below high ground water elevation. x Ariy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface T water supply. x Any portion..of a-cesspoolror.privy•is within a:Zone:I oftpublic.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 510 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 coliforw bacteria and volatile organic.compounds indicates:that the well is.free from pollutioq:fr.om:t:hat.facility and:the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than.5•ppm,provided that no other failure criteria ate-triggered.A copy of the analysis-must be attached-.to this for'Q..J . no (Yes/No)The system falls.Ihave determined that.one or.mort.of the:above.failure�criteria exist as described in 310 CMR 15.303,therefore the syste .fhils.The system owner.should contact the Board of Health-to determine what will be-necessary to con ect the failure. E. Large Systems: 'To be considered a large system the:systmm must.serve.a:facility with-a-design flow of 1,01000 gpd to 15�000. gpd• You must indicate either"yes"or"no"tq each of the following: (The following criteria apply to large systems in addition to the criteria.above) yes no ' _ x the-system is within400 feet of a surface drinking-water supply _ x the system.is within 200 feet of a tributary to a surface drinking water supply x . the:system is located In a nitrogen sensitive at'ea(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 5 of I 1 OFFICI•AL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �— $L�RSURFACE'SEWAGE DISPOSAU`SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 13 Nause.t. Lane Cent e/tVi'e ee. (7a. . Owner: K{n i/.f p n, G11 e g O%2 e Date of Inspection.: ' t LZ�_4 Q 4 Check if the following have been done You must indicate•')es"or"no"as to each.of the following: Yes No -+>i x — pumping information was provided by the Owner,occupant,or Board.of Health x Were any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? _ x Have large volumes of water been introduced to the system recently or as-part of th�mspcction? x _ Were as built plans of the system'obtained and examined?(If they were not available:hote is N/A) x 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,excludig 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? x_ _ 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 locatiod of the Soil Absorption System(SAS)on'the site. as been determined based on: Yes z Existing information:For example,a plan at the Board of.Health. x Determined in the field(if any of the failure criteria related to Part C is at issue approximation-of distant _ is unacceptable) [310 CNM 15.302(3)(b)] • u 5 Page 6 of 11 OFFICIAL 94SPEC I0N:FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSUIRFACB'SIMAOE DISPOSAL SYSTEM,% NSP:EMON:FORM PART.0 SYSTEMINFORhiATION Property Address: 13 Nau.6et Lane Cent e2vi-Lee. Na. Owner: Kn z i an Date of Inspection: 1 Z/,J�.l 0 4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desgn):A. Number of.bedrooms(actual): DESIGN flow'based on 3I0 CN IR 15.203'('for example:•110 gpd z#-6fbedro6riis):1'10x 3=3 3 O gl2d Number of current residents:'.: 4 Does4esidence have a garbage grinder(yes or no):rz o Is laundry on a separate sewage.sysiem.(yes-or.no)ri_Q_ [if yes separate inspection required] Laundry system inspected(yes or no): rig,3 Seasonal use:(yes or no): 'n o Water meter readings,if available(last 2 years usage(gpd)): Sump pum (yes or no): n o Last date o�occupancy:gae.h,,0a1 COMMERCIALfM- USTRIAL Type of estatt nt: rza. Design flgv✓ ''',d on 310 CMR.15.203):. n a �pd Basis.ofdi;Sipri�flow(seats/persons/sgft,etc.): na Grease trap'present(yes of no):Ana Industrial waste holding tank present(yes or no): n a Non-sanitary waste discharged to the Title 5 system-(yes or no): na Water.meter readings,if available: na Lastdate of occupancy/use: n a OT9-ER(describe):. GENERAL INFQIMATION Pumping Records Source of information: . Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: gallons--How was quantity.pumped determined? Reason for.pumping: TYPE OF SYSTUM xx 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 tatik _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 or no):n o 6 _ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A PART C SYSTEM INFORMATION(continued) Property Address:_'3 No„ A o f f n n o Cenfon>>j00o mr, Owner: gn i f o n GP o ran ;2e Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Z 4" Materials of construction:_cast iron x—�40 PVC other(explain): Distance from private water supply well or suction line: Q' f Comments(on condition of joints,venting,evidence of leakage,etc.): caht 4o evidence. oZ Poaka th2ough .the hou-3e ventz. ��S '�tem vended SEPTIC TANK:y LAlocate on site plan) Depth below grade: 2 6" Material of construction:xx concrete metal fiberglass_polyethylene --other(explain) — ' If tank is•metal list age:n o Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) —, Dimensions: 70' 6"iong/5 ' 8"wide/5 ' 8"high Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 4" Distance fiom top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ 1 Q" How were dimensions determined: M e a u 2 e d' Comments(on pumping recommendations,inlet and outlet tee or baffle conditio structural irate as related to outlet invert,evidence of leakage,etc.): n' ZtY,liquid levels evidence GREASE TRAP: n o(locate on site plan) Depth below grade: -n a Material of construction: concrete_metal_fiberglass_polyethylene_other (explain): n a Dimensions: n a Scum thickness: n n Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee oubaffle: n a Date of last pumping: n a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): gzeaae tea 12 not 2e,3ent, Title S TnanPnfinn Vt%rm Arl bonne 7 l Page 8 of I I ©#TICIAE INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ';A-CE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART C SYSTEM INFORMATION(continues}) P.ropertyAddress: 73 Nau.6et Lane ( Pnfon))i Cfo, 4r., Owner.• _ _ __ Date of Inspection: TIGHT or HO-LDING TANK: n o (tank must be pumped at time of inspeotion)(locate on site plan) Depth below grade: na Material of construction: concrete metal_fiberglass--_—polyethylene other(explain): Dimensions: n.ar Capacity: na gallons Design Flow: n n gallons/day ` Alarm present(yes or no): _rza Alarm level: . n n Alarm'in working.order(yes or no);rr r, Dote of last pumping: n_r. Comments(condition of ai.arm and float•switches,etc.): Tight hoPr/in.n to rl 6 i •oY 4/7AAonf. DISTRIBUTION BOX: yeas(if present must.bs 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.):. Hox -i.6 eevee.,No evidence o,e -eeakacie . .in.t<o 02 odto�e gox.� No. 3 igl2z,, OZ Ao2idi ,crL/uo.ve2. PUMP CHAMBER: no (locate on sife.plan) " Pumps in working order(yes or.no): na Alarms in working order(yes or no): na ' Comments(note condition of pump,chamber,condition of pumps and appurtenances,ett;.): - umR chamge2 not P2ez'en.t., Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS �. SUBSURFA�CE-SEWAGE.DISPOSAL:SYS�'EM INSPECTION FORM PART,C SYSTEM INFORMATION(continued). Property Address: 13 Nauze.t Lane • Confonu.LPa.. lrin_: Owner:. e Date of Inspection: 1 1/J A/0 4 SOIL ABSORPTION SYSTEM(SAS):_.(locate on site plan,excavation-not-required) If SAS not located explain why: Located zee 12,age 90 Type _leaching pits,number:_ leaching chambers,number: 4 leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative'system Type/name of technology: Co- mments(note condition of soil,signs of hydraulic failure,level ofponding,damp soil,condition of vegetation, etc.): � Sandy �3o-U 4o zignz o.1 hadltau 4a-ZP•ua No eyidpaoo o,e izond-ina Vean.taLi 0 n JA noama P CESSPOOLS:no (cesspool must be pumped as part of inspection)(locate on site plan) Number and,configuration: na Depth—top of liquid to inlet invert: HE Depth of solids layer: . n.a Depth of scum layer: na Dimensions of cesspool: na Materials of construction: na Indication of groundwater.inflow(yes or no): na Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce,6,6 oo.eZ no-t 2esen.t.' PRIVY: no (locate on site plan) Materials of construction: na Dimensions: na Depth of solids: na Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.): �2cv not 2eZen,t.' ?age 10of11 pFF�CiA�•YNSPF.' T.10N-FOR�VI,*NOT 'SYSTEAUNSPECTION FORM TS SuSSU Ej)ISROsAL` PART C SY•S`FFM PMRMATI.0N(nontinued) Property. Address:9 3 N a u g� Lan e Owner: ff n.i 4 f a n e Date of Inspection: SKETCH OF SEWAGT•DISPOSA,L SYSTEM a sketch of the sewage disposal system including ties to at least two p� the bu lding.dm"�Dr provide • benchmarks.Locate all wells within 100 feet.Locate where pub uPP. / CM (P low 10 Page 11 of 11 - OFFICIAL'INSPECTION FORM—NOT FOOSAL UR VOLUNTY SYSTEM INSPECT ON FORM ASSESSMENTS SUBSURFACE SEWAGE DISPPART. C SYSTEM INFORMATION(continued) Property Address: Owner:L a_,�.�- G2P C/O L22 Date of Insp ection: SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water�11D_feet Please indicate(check)all methods used to determine the high ground water elevation: design lams on record-If checked,date of design plan rgviewed: Obtained from system !gn p _Observed site(abutting property/observation hole within 150 feet of.SAS) Checked with local'Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database:explain: You must describe how you established•the high ground water elevation: used-Gahert & Miller model 12 used-USGS observation w used- :'Tech ical bul — wa er a eva ions. ` L 5C11. g sect Ground water Fcct Below Bottom-of Pit High Groundwater Adjustment 1.8 ft per VnptejMethod Therefore,the.vertical•separation distance between the bottom of the leaching pit and the adjusted groundwater table is •�. feet. • 11 '"r"1•�'T•Tl.r l,.•P9,,.,.-1•.5*�T�RI' IUNN UP�'^ ale , WARD OF 21EA.LTI1 y' SU113URFACF SENACF 1)1S1'UraA.L %YST�M IN8I1� FCTION FORM - PART D CERTIFICATION 1 , T.IIR�.�ITSM15,11'1/ltTlpwR,R41tT.�179'•- 5'1511RRt:f������•�-'•""' ' -TYPE OR PRINT CLEARLY- PROPERTY XNSPECTED STREET ADDRESS 13 Nau,6et Lane ASSESSORS MAP , DLIOCK AND PARCEL # OWNER•' s NAME lC2i�sten �e oc2e PART U - CEftTXF10AT.rON NAME OF INSPECTOR COMPANY NAHE Joseph P. Macombex &' `Son Inc COMPANY ADDRESS Box 6_0 Centerville Mass 02632 Wn or c ty State LIPI' street COMPANY TELEPHONE ( 508 ) 775-3338 i FAX ( 508 ) 790-1Z78 C(3RTIFICAT•ION. STATEMENT I certify that I ., have personally ��gort�adishtl^UeWa�cout'ate9aandsystem • ;.this address and that the information p Complete as of the time of inspection, The inspection was performed and any 'recoln(nendation$ rega.rding ui-�grRden maintenance ,f�unctionpair are and maintenanceent of o with my' training and experience i pr site sewage disposal - systemsl Gheck one ; , xxx System .MASSED The inspection which I haVe condu-p.ted .has not found any protecformation wh s ich indicates that th•e system fall toadequately health' or the environmeaadste it 303 . f ailtire reastadn he FAILURE CRITERIA section c criteria not evaluated this form . �, _ Sys tern FAILED* The inspection which I have con -Voted. has found that the system fails health and the e��i�'natedtonnPART accordance FAILURE Titl.E protect the E)ub.lfc 5 , 310 CMR 16 . 3Q3 , and as speciflca y CRITERIA of this inspec ion fo ttt , ate -/ Lv `� Inspector Signature . F ;ine copy of this �c nd.f lcetxiionit�ust be Vrovided to the QWNER, the BUYER ( ++hero e6pplicabl® ) a If the inspection FAILED , chi heow- inspection•,, t nless shall alloweddor' the requiredm within one year of the dnt.e of R1 otherwise as provided in �.10 CPiR 16 ,_3,061 partd . Septic SC'-vi cC (508) 863-7433 (508) 548-3385 + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 20 Address of pro pert ��J Na���' 1 .C�1 Owner's name Date of Inspection PART A CHECKLIST Check if the following have been done: dumping information was requested of. the owner, occupant, and Board of Health. _4,1,?tone of .the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ai�i As built plans have been obtained and examined. Note if they are not available with N/A. t/The facility or dwelling was inspected for signs of sewage back-up. ✓The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The ptic tank manholes were uncovered, opened, and the interior of -the septic tank' was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. �—�The size and location of the SAS on the site has been determined based on exist: ng information or approximated by non-intrusive methods. Tfacility owner (and occupants, if different .from owner) were provided with information on the proper .maintenance of SSDS. • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents _1(�j( garbage grinder, yes or no _V A PI�laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: Slam System pumped as part of ins ection P , es or no if yes, volume pumped 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) Other (explain) i rf (' c Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arriving at the site, yes or no r � 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART 8 SYSTEM INFORMATION Continued SEPTIC TANK: �( (locate on s to plan) depth below grade: material of construction: concrete _metal _FRP _other(explain) dimensions: sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in.:relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs', etc. ) DISTRIBUTION BOX: -LA (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution. is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site pla ) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL BYBTEM INSPECTION FORM PART B SYSTEM INFORKATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number , leaching chambers and number -. leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of pondin condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) n Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) Y-\ PRIVY: �1 (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, .signs of hydraulic failure; level of ponding, condition of vegetation, recommendations for maintenance or repairs etc. ) • 1 1 11 _.SUBSURFACE SEWAGE DISPOSAL 'SYSTEM INSPECTION FORM 4?ART H SYSTEM INFORMATION coutinuod SKETCH OF SEWAGE DISPOSAL SYSTEM:. include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �Clc C 4ff BA 96 DE H TO GROUNDWATER depth to groundwater method of determination or approximation: 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", a:,plain why not) Jam— Backup of sewage into facility? Discharge o g r ponding of effluent to the surface of the ground or surface waters? �Ntatic liquid level in the dist ribution box above outlet invert? Liquid depth in cesspool �� flow? <6 below invert or available volume< 1/2 day Required pumping 4 times or more in the last year? number of times pumped Septic e tic tan �P k is metal. cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank . failure imminent? Ts any portion of the SAS, cesspool or privy: below the high groundwater elevation? v within 50 feet of a surface wate r? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well. within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, u„o the SAS)? .. within 50 feet of a . private water supply well? r less than l00 feet ,but greater than 50 feet from a private water supply well with no acceptable water quality .analysis? If .the well has been analyzed to be acceptable, . attach co py of well for coliform bacteria, volatile organic compounds, ammoniatnitrrogen� and nitrate nitrogen. ' •. 19 SUBSURFACE SEWAGE DISPOSAL--�8YSTZX INSPECTION FORM PART jD Y CERTIFICATION Name of Inspector Company Name NEW LIFE SEPTIC SERVICE Company Address P.O. Box 2119 Teaticket, MA 02536 (508) 548-3355 Certification Statement I certify that I have personally .inspected the sewage disposal system at this address and that the information reported 1s, true, accurate and complete as of the' time of inspection. The inspection was.performed and any recommendations regarding upgrade, -maintenance and repair are consistent with my training and experience in the proper function .and manitenance of on-site sewage disposal systems. r Che one: . I have not found any information which indicates .that the system fails to adequately protect public health or the environment as defined in 310 CMR ,15.303. Any failure criteria ,not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The-basis for this determination is provided An the FAILURE CRITERIA section of this form. Inspector's Signature Date original to system owner Copies to: Buyer (if applicable) Approving authority y Tp KEY NUMBER <3871 Niu•fE <WASELSKI , JEANNE > B—C 3 �}—C 3 B—C 4 STREET 13 NAUSET LN � CITY CEWTERVILLE S2' MR 3IP 026.32--2923 ?.EF 1 F:EF 2 PHONE ( ) — a ' REF 3 REF 4 s � \ -METER NO. < 3561 > - - --- _ DATE FEAD1NG t� STREET <NAUSET LN NU 13 12/31/94 256 ; CITY t EPJ K L25 gT ` LOC 06/30/94 220 26 PHONE 1?_/31/93 194 � r s — 06/30/93 1431 ROUTE ,NUid$E;R 32 1?./31/92 11.2 2 5. SERVICE DA`.;'E 07/08/70 = 06/30'/92 87 # METER DATE 02/27/91 12/31/91 60 , 40 Cr,PACITY 7 06/30/91. 20 25 STYLE T14 SIZE 1 r P.R'I'E SCHEDULE r 1 KEY PIT PLASTIC i NOTE RR LEFT FRONT ALDITIO'r+?',L CONS U -t-. ALTERNATE MTL N 0 Viz•-� � �;„ n. .of Y e psta a 3 '�K A �' .r✓Y 4 "1`1 &R. 1 �'J-S ti' K Fw�``.�� ,�,�,���'��"5-z'x S>� ♦ r rs_ u i e t� a ac axq�'� „�..a �.� t a 11-0 a xr x »• '1{ �'"s� } 0{ -^�,,�,e'�P:b'4 C� •,y�' ,. : ��„F�'.w7•�`J'.*i�_ �� '� i�`"'a r'�F+k 'k r ,,{yr��„? ,m1^ - .Sr ♦ i t ;,a �' �.�s ��4a yii,'I• .. � G c #�k�nysy'rb} t r'1�4�+ 7. 9R,,�; a i;, �.�1P' ✓ `' ,} '�,w �y-.r sp 'Y+�t^' r. •h'P�- 'vy ?�^Ye 4 E3,11" d'.t...r�,,§"`�'`k" ,v F w R"y'•`�r w � �' � b '�.ra ��x� All ai:' w ka 7a p Tim, re S '�r'" '�"`��.� �n'� �...- �,„� ..; .�� . .,,..__'�." � a k��xY'; ?���"di3s ^, _.9 �.��'#�,r. ._.•.. ,{;2� xz�,'i��� `�_�..�'�S �x' ,,'sN^,,�.' .... � r4 , � TOWN OF BARNSTABLE L ` :ATIONz2 I Vnc",0 SEWAGE # VILLAGE � �� ASSESSOR'S MAP & LOT 329 S5 INSTALLER'S NAME&PHONE NO. SC1S SEPTIC TANK CAPACITY I so-a 2 LEACHING FACILITY: (type) x (size) �� 5 NO.OF BEDROOMS cx 3�i X a� BUILDER OR OWNERS PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 10 ,S Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 2 feet of leaching facility) IO Feet Edge of Wetland an• Le ching Facility( etlands exist within 3A0 feet f leaching facility) Feet Furnished by ? -� D 0 4o � Y TOWN OF BARNSTABLE LOCAhON 0ANS6 W'Nt SEWAGE # A _ 'a`II,LAGE CEIMP-Cdo N, ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. d11 SEPTIC TANK CAPACITY M0 Q6A&V\% LEACHING FACIL=: (type) (size) NO. OF BEDROOMS— BUILDER OR OIAINER �� '< Ot��arah �►�be� s PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) OW h►A6 _Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) f� Feet Furnished by °��no �o t on���U��'2u 125nbN �� l No. ���� Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: k Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfication for Migogal *pgtem Construction Permit Application for a Permit to Construct( , Repair( )Upgrade( )Abandon( ) ❑Complete System 201�dividual Components Location Address or Lot No. � /�1f3vs Owner's Name,Address and Tel.No.3 �t L IV Assessor's Map/Parcel � �/` �! �h t4 R ObL�S Q — 2 T� F� f11v ttG G Mr Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ;17/ -2 VZq Type of Building: Dwelling No.of Bedrooms f� Lot Size sq.ft. Garbage Grinder"b) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow (4 yfl gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �D o Type of S.A.S. t/ $D So s Description of Soil; 1M: jf _4 x a Nature of Repairs or Alterations(Answer whe/t}ap licable) 1 P1 s t A t7 i� i�a � C 7r �O.D2 F1L finorel or?s Q 1 O'r Sk b�e s(:LS`T 81' 5 iga X II 'x2 - 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 s B f all Signed Date Application Approved by Date � 5, Application Disapproved for the following reasons s Permit No. ��6� ;� '� Date Issued 5 --1Ze—rf K No:aaC �i . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer_r Yes PUBLIC fHEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 010pYication ,for Migogal *pgtem ConMruction Permit Application for a Permit to Construct( _Repair( )Upgrade( )Abandon( ) ❑Complete System 41ndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 3 )IVA 1/S rf L IV Assessor's Map/Parcel l y1 .-/6✓ �r fir L ^nb tOS iriser's'Name,Address;and'Tel!No:_. f Designer's Name,Address and Tel.el.No. � 7 T.pe-pf; uildirig: •. , ! . ` ;�_ ` bep. lling No.oaf edrooms' Lot Size 'sq.ft. Garbage Grinder(�) ;'1 1 OtheP Ty_p_e r ,uilding-1 �/ ;No.of Persons Showers( Cafeteria( ) he—'ixtures �. Design Flow '�f— � =- gallons per day. Calculated daily flow gallons. .-:=P1an Date1 Number of sheets Revision Date ^-- r-` IT,i#le 1 r/- -Size of Septic Tank ��n o G A Type of S.A.S. t/ go 50 s Description of Soil; Iti,> 0(j4HA Nature of Repairs or Alterations(An§ e end` licable), 1 s�' I ...n 1 Oa a : Yi = ;�rr:l / of S/ Date last insp 5ted: ` Agreement: /The undersigned agrees to ensure the construction and maintenance of the afore desc 'bed 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 s Bood-of Health. Signed G,�t ell- Date Application gtion Approved by Date d16!!! " 'zg�y/ Application Disapproved for the following reasons Permit No. � Date Issued l -------------------------------W� .__---- THE COMMONWEALTH OF MASSACHUSETTS B4 NSTABLE, MASSACHUSETTM. 7 U, I Certificate of Compliance �LI'S THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned ( )by 7,0P"PC kFR at 14 //,q u<r f L ti L r nA t-r W//Z- X has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permitg!�J/��� dated �� e`=Av Installer 31N wn Es br.,pLA FR Designer_ /1 , _ The issuance of this�e/ 4t shall n t be construed as a uarantee that the system will function a desi ed.'i g Date 2� �2 Inspector, o -1 - �� r ------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE., MASSACHUSETTS Migpogat *pgtem Con!9truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at I `� A/A & S�� L /L r rr,1-e C; 1ii//r- 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 thi lit. Date: 45r- Approved ! 1/6/99 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 DESIGNED PLAINS) , 1, J-Pole hif3LhM , hereby certify that the application for disposal works / construction permit signed by me dated , concerning the property located at 1 JIA114r f- L y meets all of the following criteria: �• This failed system is connected to a residential dwelling only. There are no commercial 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. f• There are no wetlands within 100 feet of the proposed septic system �• There are no private wells within 150 feet of the proposed septic system �• There is no increase in flow and/or change in use proposed Y • There are no variances requested or needed. �• The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation._[Adjust the groundwater table using 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 maximum adjusted groundwater table elevation, Please complete the following: pr A) Top of Ground Surface Elevation (using GIS information) q - B) G.W. Elevation +the MAX. High G.W. Adjustment . DIFFERENCE BETWEEN A and B ^ SIGNED : DATE: (�j&—2_��P7/ [Please Sket proposed plan of system on back]. NOTICE Based upon the,above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert 5- \rk- Tin- Pr T a r 27 x i► i X 2-. / ---fp�xa,� � TOWN OF BARNSTABLE LOCATION 1!5 NNW "Arid SEWAGE # -4 A VII.LAGE GQ9(1k—C i 1' I _ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SMM Wa I '��. 5V SEPTIC TANK CAPACITY 1500 01A LEACHING FACILITY: (type) (size) NO.OF BEDROOMS I' BUILDER OR OWNER 000rth %)kckk PERMIT DATE: 1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) a�3nQ�Z� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i ! '3 .Nausef Lane,CtAtcrvi t le 01 - 3a 3� ° n U. TO ALL NEW BUSINESS OWNERS � F- DATE: Fill in please: ® ck(� L � s APPLICANT'S � � ^ . YOUR NAME: ����N i BUSINESS YOUR HOME ADDRESS: N��Ssc ( �► S01 3Cq az." (lk 106 0z(6 3 2- TELEPHONE Telephone Number Home Sol -1q0 3( S 1 NAME OF NEW BUSINESS . l° S TYPE OF BUSINESS ac,.A e IS THIS A HOME OCCUPATION? YES y NO Have you been given approval from the building division? YESP11 NO ADDRESS OF BUSINESS 13 N av Srzt LPJ C�-,A ,. 17 P\11 6 a MAPIPARCEL NUMBER When starting a new business there are several things you must do in order to be incompliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained the required signatures, listed below, you may apply for a business certificate at the Town Clerk's Office (Ist floor-Town Hall) or if you get the business.certificate first you MUST go to the following office to make sure you have all the required permits and licenses.. GO TO 200 Main St.-(corner of Yarmouth Rd.-& Main Street) and you will find the following offices: 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature" COMMENTS: 2. BOARD OF HEALTH This individual has beDni f the permit requirements that pertain to this type of business. .4thorized Signature" COMMENTS: I1 S 3. CONSUMER AFFA RS (LICENSING A HORIn�i This individual has be formed of the liens' ements that pertain to this a of business. P type A on ed Signature" COMMENTS: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. -it does not give you permission to operate -you must get that through completion of the processes from the various departments involved. "*SIGNIFIES APPROVAL FOR A BUSINESS CERTIFICATE ONLY. �.� Date: 6 //2 /dC., TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 1_) Schoke.nby L. C • BUSINESS LOCATION: 3 /yc�vse �, � Cenkto�i�� c�2ln3z INVENTORY i MAILING ADDRESS: TOTAL AMO NT- E TELEPHONE NUMBER: .0S 3(0 Lt 0 L(o (o t. CONTACTPERSON: �1�k�-���✓�- L ���5 EMERGENCY CONTACT TELEPHONE NUMBER:__51Nd AG L-1 OZ O G MSDS ON SITE? TYPE OF BUSINESS: JkDrever °I w.nba Iv e_ ,__n-- INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid, Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers �1G (including bleach) / �� eS . Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS No......�!.�Ll 0 FEs ,.......�.� ... TF;�COMMONWEALTH OF MASSACHUSETTS ell— BOAR® F HEALTH ., ,..... of..... -----------------•---- AVp iration for Uiipuial Works Tonstrnrtiun runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. �C 1 ................................ ........... -•••-•----.............................--.......... a s O ner Address _.....=J� . � ..... ........... Installer Address d Type of Building/ Size Lot............................Sq. feet U Dwelling No. of Bedrooms................................. .....Expansion Attic ( ) Garbage Grinder ( ) ~ Other—Type e of Building ---------------------------- No. of ersons.....................------. Showers — p,, yp g p ( ) Cafeteria ( ) Q' Other fixtures ---------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Gd Septic Tank—Liquid*capacity....---.....gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. i................minutes per inch Depth of Test Pit..............----.. Depth to ground water-----................--. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit------.............. Depth to ground water......-----.---......... P4 e----- ----------- /`-----••-•-----------•-•-•-----•------•--------------•------------------•-•--•--.....----•------•-- 0 Description of Soil.......... - x - - -------------------------------------------••--------------------------------------------.....----- V -•--•-••-••••-•--••---------•----•-•-•---•••-•--••.....••••--•••---•--------•-•-•••..........-•--•••---••---•---•-------•-----•-----------••••-- Z4 -------------------------------------------------------------------------------------------------------------- --------------- --------...... U Nature of Repairs or Alterations—Answer when applicable... _......,1 ........ i! ....................... --•-----•------•-•----------•---•------------------------------•--..............................---•----•----------------------------------------------------------------------------------.........--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by he oar f healt Signed ...........e_ ............... ....... �.. Date Application Approved By.............................. .... .............` I �2-'/r�-.. ......................•----.... ........... �.._ Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ................•-•---••••-----------.........................•--•----•-•---•-•--•----------•-••.......---•-----------------•-•------••---•-----•-•--------•••-------•-•••-----••-•-- Date PermitNo......................................................... Issued....................................................... Date No...... T1-,!%COMMONWEALTH OF MASSACHUSETTS BOARD , F HEALTH r 7 �m �" '------......OF..... `.� l n X��- ... } r`ir;rHt ,:'......................... ` Appliration for Diaiposal Works.. Tanstrurtiott Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ......... � ------------------•-•---•-•---•---------------.....•----•-----_..._.....__.................. ' Location-Address J or Lot No. Owner. Address yy� f�j _ I P J 'c Installer Address dType of Building,," Size Lot............................Sq. feet U .� Dwelling=No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other>—a � Type of Building •-------•----•---------•---• No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------------•...•--------------------------------------._...-•••-•............................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_---------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_.___-_______-__:_---__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil-------- :? 4� = -- - - --- - x W . ---------------------------------------------------------•-•---...................... ----'---� -------� -------- ------------------------------- U Nature of Repairs or Alterations—Answer when applicable.... -"_/___:___/ _:' ... ....................... x ' -..._.�.�.. ------------------ -••----------•--------------------------•-----•---------•--------------------------••-----•------------------•-•--•-•-----•---------•----------•••-•--•--------------•------.....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system,ein operation until a Certificate of Compliance has been issued,byr-the bfoal;d of health,. r d �r Signed �e.11f.: *"1N... ;` F� !r� r""r ,.! 1"✓1r � � f ................................ Date Application Approved BY....................... ...... = . ................= Date Application Disapproved for the following reasons:...........'I•---•-----•--------------------••--•------•----•------------.._.....-------••--....------•--....._ .k lq .........................................................................................................._........_...._._._........._........_........-•-----........-•-•----.....................�.... Date PermitNo......................................................... Issued_--------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... '' .......O F........ h: r%° ........ Tntifiratr of Tontpliatty THI,S.IS, OF�R IFY, at the Ind vidual Sewage Disposal System constructed ( ) or Repaired ( ' by-- i.� � ! �'�i �. . ., ...................................................•.-------•--- r� at-- ..+ ...........a ... l ----- ... r.... ..'.� ..� ''-----�0...r� .... has been installed in accordance with the provisions of TI T LE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.___. C -�/X24...... dated____________________•_______-___-------..----.-. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....................................7 L::./� ........-•--........_._. Inspector `' I 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH �...........OF.... ........ f;,�f „ No.......... -------------- FEE.. ...... o%hp Tonotnu tiny rrntit- PermisionIs hereby granted.....--........................................... ....... ........ -----------....--------.................... to Construct ( ) r/Re flair. ,,�ary�Ind�v�ual Se D ypos��Syst��r at No..,Z,.....---�"z ,f� _�.sir �r�. �� � --------------•-----------------.............. Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ................... �- .............................................................. Board of Health DATE..... 'r -------------•----- FORM 1255 A. M. SULKIN, INC., BOSTON L LO;-C A T ION SEWAG E PERMIT N0. VILLAG INSTA �ER'S NAME i ADD E S S e U I L D E R OR OWNER -..Lmm9 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �L��l Irk � 3