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HomeMy WebLinkAbout0705 OLD STAGE ROAD - Health 705 Old Stage Road (Centerville) A=191-174 UPC 10259 No. H� 630R 'tisi.co `' HASTINGS.MN TOWN OF BARNSTABLE LOCATION ���� 01-D STA6c RC SEWAGE # RQ— v�6D VILLAGE (A I C/Vi�lS1_� ASSESSOR'S MAP & LOT Y INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /ODD GA). LEACHING FACILITY: (type) i��T (size) NO.OF BEDROOMS 3 f BUILDER OR OWNER 3 ✓VI CCA W.Tk I' PERMITDATE: COMPLIANCE DATE: " 8O Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of 1 aching facility) _ Feet Furnished by S �c. �rtSpC ion .� .FOB y ;0 30o I I 'beck, I � e Qj • ace' a Aa- �, 3 A+r ,a3- 3N �y 31�10 0 y A /p Lb CATION r S, SEWAGE PERMIT NO. VILLACEOe -),, j ey' vI � � �o I N S T A LLER'S JJ NAME i ADDRESS 1 Ayc. h Co -y1 S' 7- 8 U I L 0 E N OR OWNER DATE PERMIT ISSUED 7 DATE COMPLIANCE .ISSUED�� �, �� 2.3 (� No. l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in com uter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitatlon for Disposal *pBtem Construction Permit Application for a Permit to Construct( ) Repair)( Upgrade( ) Abandon( ) [:]Complete System Individual Components Location Address or Lot No. ®fj ®CJ) �j'"(F' 6 PZ Owner's Name,Address,an Tel.No. Assessor's Map/Parcel L°Y Vf" "A ( r. __ I Ca .6 c-A S fuuf Installer's Name,Address,and Tel.No. 509-`f T 7—OV 1 f Designer's Name,Address,and Tel.No. Gc� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this Board of Health. Q Signed Date Application Approved by Date ��)' Application Disapproved by Date for the following reasons Permit No. �" j� Date Issued v 1 i r^ No. 15 t S Fee dcJ— _ . THE COMMONWEALTH OF MASSACHUSETTS Entered.in computer- PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS - application for MispoSal 6pstem Construction Permit Application for a Permit to Construct( ) Repair YV Upgrade( ) Abandon( ) ❑Complete System [,Individual Components Location Address or Lot No. '7 p 5 O LI) 5-T rIC-6 RZ Owner's Nam/e,Address,an Tel.No. Assessor's Map/Parcel C Vr44 E",ARL4/ DA57ILVA to o c_o S -e- Ab GC (Lcc5 Installer's Name,Address,and Tel.No. 508 `{7?-88117 '\,Designer's Name,Address,and Tel.No. C40C-W(i�G EN rLw. fsF� , r cow N 1/4 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) =iUs JU�� D -OcX 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 Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by Date - for the following reasons 4 Permit No. Date Issued .2 cp.-" THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�) Upgraded( ) Abandoned( )by �it�6(,y(bE l ti g 565 L.L(L at 7705 6a 57*4=6; R,b �t(/((,(,� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. C1 dated Installei0APF,w(0C WAJ0 LLC Designer NIA #bedrooms � Approved& gmftow gpd The issuance of thi pe S it shall not be construed as a guarantee that the system wil funct nr a' designed. Date Inspector V �' q -- ---- ------------ ------------------ ------------------------------------------------------- No. Z0 O ✓ Fee wC'THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposat 6pstem Construction permit Permission is hereby granted to Construct( ) Repair(k) Upgrade( ) Abandon( ) System located at l 0 5 Q Lb SmxG65 Ro kb -r_ei V L Lz_i_- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons ction/must be completed within three years of the date of this permit. 1 Date ,2 /( Approved by "V" � AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION �S OLD A65—' RC! SEWAGE# RID- ZLa(D VILLAGE Ct ftVik ASSESSOR'S MAP&LOT!°1 I7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY _ I QM GAI. LEACHING FACILITY:(type) 1P iT (size) X(P - I $T-O/vL NO.OF BEDROOMS 3 BUILDEROROWNER aQ� ry►vrAwsk PERMITDATE: COMPLIANCE DATE: -'9" SO Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of Ipching facility) 1 Feet Furnished by__ -Syh . �+'1S�etT'Qn FOe J `1/;o aoo i i %A 1 '4 i Al- 11 10 „ 61• 2U, a a3- 3y aq, qI to http:/Assgl2/intranet/propdata/prebuilt.aspx?mappar=191174&seq=1 8/28/2015 ep 03 1512:07a / n p.1 Commonwealth of Massachusetts I! Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments T 1 r r^t 706 Old Stage Road Property Address Harley Silva `. Owner Owners Nameinformation = required lg Centerville MA 02632 9-2-15 required for every �-r - page. City/Town State Zip Code Date of Inspectionµ Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information on the compu tng out er, forms �N O�'IygSsq�•�% use only the tab p key to move your 1. Ins actor. cursor-do not James D.Sears _ ; JAMES ;LP use the return Name of Inspector key. CapewideEnterprises,LLC CI_ Company Name 153 Commercial Street 5 INSPi-C"�i Company Address Mashpee MA _ 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-2-15 nspectors 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. vl 15ins.3113 TWR 5 Ofrfdal Inspection Fain:Subsurfeoe Sewage Disposal system•Page 1 ur 17 Sep 03 15 12:08a p.2 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner Owners Name information is required for every Centerville MA 02632 9-2-15 page. cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D Al 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 system is a 1000 Gal.Tank D Box and pit 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 ❑ NO(Explain below): i tsim-3113 Title 5 Officiel Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Sep 03 1512:08a p.3 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner Owner's Name information is Centerville MA 02632 9-2-15 required for every page. City/Town state Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired. B) System Conditionally Passes (cunt): ❑ 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 i i tsine•3r13 Tive 5 omcjal inwecilDn Form:Subsurface Sewage Disposal System-Page 3 of 17 i Sep 03 1512:08a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 705 Old Stage Road Property Address I Harley Silva i Owner Owner's Name information is Centerville MA 02632 9-2-15 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certificd 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 sell is less than 6" below invert or available volume is less than'/:day flow 00!7— (Sins•3M3 Title 5 Official inspection Form:SubsuAace Sewage Disposal System-Page 4 of 17 Sep 03 15 12:09a p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 705 Old Stage Road - Property Address Harley Silva - Owner Coroner's Name information is required for every Centerville MA 02632 9-2-15.- page. City/Town State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation_ ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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, j 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 20009pd- ❑ ® 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. I 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. t5ine•3113 Ti3a 5 Officlal hspadim Form:Subsurface Sewage Disposal System-Page 5 of 117 Sep 03 15 12:09a p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner. Owners Name required information is Centerville MA 02632 9-2-15 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 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 i 15ins•3113 Title 5 Official Inspection Form:Subsurface SeeMga plspvsal System-Pega 6 of 17 Sep 03 1512:09a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner Owner's Name information is required for every Centerville MA 02632 9-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information i Description: The system is a 1000 Gal.Tank D Box and pit. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 0 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 years usage(gpd)): 2013-129,000Gal 2014-96,000GaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present p Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpersons/sq_fL, 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: 15ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Dieposal System-Page 7 of 17 Sep 03 1512:10a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 4 705 Old Stage Road Property Address Harley Silva Owner Owners Name information is required for every Centerville MA 02632 9-2-15 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: NA Was system pumped as part of the inspection? Q 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 i ❑ Single cesspool i ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ InnovativelAlternative 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 I ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins•3M3 Tiea 5 Official inspection Form Subsurface Sewage Disposol System-Page 8 of 17 i I Sep 03 1512:10a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva - Owner Owner's Name information is Centerville MA 02632 9-2-15 required for every page. C41'rown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of information: 1980 Permit#80-226 -9-2015 New 0 Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ®other(explain): Distance from private water supply well or suction line: Feet Comments(on condition of joints, venting, evidence of leakage,etc.): Pipeing is 4" PVC SCH-40&SCH-20. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: 0 concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 4" Sludge depth: t5i t•3f13 Tice 5 Ofrcial Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Sep 03 1512:10a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner Owner's Name information is required for every Centerville MA 02632 9-2-15 page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) I Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 1211 Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level.Tank and covers at 11" below grade. In and out let baffles. No sign of leakage or over loading. I j 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 ulna.3113 Tile 5 ofGdal Inspection Form:Subsurface Sewage Dlsposw System•Page 10 of 17 Sep 03 1512:11 a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _705 Old Stage Road Property Address Harley Silva Owner Owner's Name information is required for every Centerville MA 02632 9-2-15 page. City[Town State Zip Code Date of Inspection D. System Information (cunt.) 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•3113 Title 5 Official Inspectlon Form Subsurface Savage Disposal system•Page 11 of 17 Sep 03 1512:11 a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner Owner's Name information required for every Centerville MA 02632 9-2-15 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 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.): D Box is 20"below grade w/one line out. Cover at 4" below grade. Box is new 9-2015. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): ` If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Tale 5 Official Inspedion Form.Subsurface Sewage Dispcsal System Page 12 d 17 i i Sep 03 1512:12a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner Owners Name information is required for every Centerville MA 02632 9-2-15 page. 67t—yrrawn State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit. w/1'stone. Pit and cover at 26"below grade.2'water in pit. No sign of over loading or solid cagy over. No high stain line. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): { Number and configuration I 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 Mine•3/13 Title 5 Offidal Ins pection Form:Subsurtace Se+uage Disposal System•Page 13 of 17 Sep 03 1512:12a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner Owner's Name information is required for every Centerville MA 02632 9-2-15 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.): r i Bins-W3 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Sep 031512:12a p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 705 Old Sta a Road Property Address Harley Silva Owner Owner's Name information is required fur every Centerville MA 02632 9-2-15 page• cityrrowm state Zip Code Date of Inspection D. System Information (cunt.) 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 r � RE" �qt D p 13 - � ! ��� - •3 J '--�� 2 b ❑ 3 O � i t 15i r.5•313 Title 5 Official hSp9MM Fow..Sub&udam Sewage Disposal System.Page 15 0117 Sep 03 1512:12a p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 705 Old Stage Road Property Address Haney Silva Owner Owners Name j information is required for every Centerville MA 02632 9-2-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam.- Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells —N0 P q 3 Estimated depth t hig ground round water: 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: G.W. on file at B.O.H. and past report. Before filing this inspection Report, please see Report Completeness Checklist on next page. i5ins•3113 redo 5 Official Inspedion Forth:Subsurface Sewage Disposal System.Page 16 of 17 II I Sep 03 1512:13a p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 705 Old Stage Road Property Address Harley Silva Owner Owner's Name information is required for every Centerville MA 02632 9-2-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I r Commonwealth of MbssaChuSLtts Title 5 Official Inspection Fdrin Subturface Sewage DEsposai System Form - Not for voluntary Assessments .D D Property Address e (re � Owner Owner's Name /^ information is / (or/► ✓ ,1G Q j / 8 required for every (, Page. City/Town State Zip Code Date of Ins ion Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist atthe end of theifoim. '" m ' filling out forms s A. General Information •I on the computer, key only move the t 1. Inspector. kyour Y o %o / cursor-do not Y s use the return Name of Inspector Y Company Name �O g0-X1 rxo Company Address .4 Ss J hG — 002- 6W Cityfrown M State Zip Code ao F) 7 / ��� D �oZ 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 16.340 of Titre 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority J/71 Y /c� Inspector' 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 o4ginal 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. �i7 1 t5ins• 1/10 d1e 5 Ofrciaf inspection o I—sewage System•Page+or 17 Commonwealth of Mlassachugetts Title 5 Official Inspection Fdrm Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ?oS o l d S467�4e' d Property Address UGc / Owner ONmers Name information is //_' H ei Yr �/e pd 6 �a // I 02 required for every c�rlTown `�e State Zip Code Date of Inspection Me. B. c@1"tiflCatlOtl (coat.) Inspection Summary: Check A,B,C,D or E l 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 CM 15.303 or in 310 CM 15.304 exist. Any fa lure criteria not evaluated are indicated below. Comments: a) 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 exltration 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 Id is available. below ❑ Y ❑ N ❑ ND(Explain ): j i i Title 5 umcIm Inspe nn Forth:Subsurface Sevap Disposal Stem-Page 2 of W 15ins•11110 i f Commonwealth of Massachusetts • ec i®n Form Title 5 Official lift! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 110 Owner Owner's Name J /IAA � �� /�Z)l 8 � information is Celli4✓�i /e %/7 T required for every State Zip Code Date of Inspedi page. CdyfT6 n B. Certification (cunt.) B) System Conditiorrally Passes (cont.): Observation of sewage backup or break out or high staticwater level in the distribution box due to broken or obstructed pipe(s) or due to a broken, seWed 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 Ev aivation is Required by the Board of He�lth: ❑ Conditions exist which require further evaluation by.tha 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 deteff Anes in aCicordance with 310 CMR 15.303(1)(b)that the system is not functioning in I 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 TW.5 offi.i Inspec,ion Fortn:Subsurface S-M-ge Disposal SYSIM Pap 3 of 17 ,Sins•11/10 i Conimonwealth of Missachu§etts Title 5 aal I •�p t11 1= rm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /It.ACGl owner Owner's Name information is CeV74e ,rw� `le /i r a required for every State Zip Code Date of Inspecti page. Cityfrown B.. lbertification (cunt.) 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 AS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the�AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is I�ss than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance. - Thisperformed�t a DEP certified laboratory,for fecal *" II water analysis, This s stem passes if the we Yg coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal i to or less than 5 ppm, provided that no other failure critena�re triggered copy of the analy sis must be attached to this form. 3. Other. I D) System Failure Criteria Applicable to All Systems: r ,r rr " of the fo�towin for all inspections: tions: You must indicate `Yes or No to each g _ p Yes No ❑ Backup of sewage into facility or sy,tern component due to overloaded or clogged SAS or cesspool ❑ Q/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged S�S or cesspool Static liquid level in the distribution lox above outlet invert due to an overloaded or clogged SAS or cesspool Q Liquid depth in cesspool is less tha� 6" below invert or available volume is less than '/2 day flow Tale 5 0 I Inspection Form:Subsurface SewageD40SM Soern•Page4 of 17 Gina•11/10 Conhmonwealth of Massac usetts yjTide 5 ®1fielisl Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntan Assessments old eed Property Address ' Owner Owner's Name / information isCQN e ✓', �IrISD� n �9e ed for every City/1 ownState Zip ode Date B. Certification (cont.) Yes No ❑ ;Required pumping more than 4 times n the last year NOT due to clogged or obstructed pipe(s). Number of times p mped: ❑ Lr Any portiornof 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. ❑ Ej"� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is ithin 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 an lysis, performed at a DEP certified laboratory.,for fecal coliform bacte 'a indicates absent and the presence of ammonia nitrogen and nitrate ni ogen is equal to or less than 5 ppm, provided that no other failure c ritei ila are triggered. A copy of the analysis and chain of custody must be atta hed to this form.] ❑ The system is a cesspool serving a fc icility with a design flow of 2000gpd- /101000gpd. ❑ �-,/ The system fails.I have determined that one or more of the above failure tt� criteria exist as described in 310 CIVIR 15.303, therefore the system fails. The system owner should contact the Bo rd of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the#ystern must serve a facility with a design flow of 10,000 gpd to t5,000 gpd. For large systems, you must indicate either"yes" or"no" tc 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 f a public water supply well If you have answered"yes"to any question in Section E tie system is considered a significant threat, or answered"yes" in Section D above the large system h s 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. rail 5 orfi al Inspection Form:Subsurface.Serege D405W sham•page 5 or 17 Commonweakh of Mas►'sachusetts Tide 5 Official Inspection Form Subsuface Sewage Disposal System Form • Not forr Voluntary A ssessments p . Old 7-6"? Property�Address / Owner Owners Name '/ ©� information is (/ � required for every Crty/Tovm State Zip Cod Date I on page- C. Checklist Check if the following have been done. You must indicate "ye " 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 pu ped out in the previous two weeks? []/ ❑ Has the system received normal flows in he previous two week period? ❑ ,--,/ Have large volumes of water been introduced to the system recently or as part of L"J this inspection? ,--,/ ❑ Were as built plans of the system obtainiEd and examined?(If they were not l� available note as N/A) [[]�❑ Was the facility or dwelling inspected for igns of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding a SAS, located on site? Q� ❑ Were the septic tank manholes uncover, d, opened, and the interior of the tank inspected for the condition of the baffles r tees, material of construction, / dimensions, depth of liquid, depth of slu ge and depth of scum? ,_ ,/ ❑ Was the facility owner(and occupants if different from owner) provided with lLL�77 information on the proper maintenance f subsurface sewage disposal systems? The size and location of the Soil Ab rption System(SAS)on the site has been determined based on: Existing information. For example, a pla 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): 2 Number of bedrooms (actual): 7 J �(2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1-d%5 OfflaW t pect—Forth:subsurface sewage Disposal sygem•Page 6 of V isms•11/10 Commonwealth of Massachusetts Tide 5 Official Inspection F rm Subsurface Sewage Disposal System Form- Not for Voiunta Assessments Property Address " G' (2,1114 GC i Owner Owners Name information is �(�� ` J/ pie. ity/town required for every State Zip ode Date of nspe on C D. System Information Description: / r_ze �DoO q a Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 1�1"No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes Uwo-- Water meter readings, if available(last 2 years usage(gpd ): Detail: Sump pump? ❑ Yes N-0 Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment. Design flow (based;on 310 CM 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: Title 5 offic ai Inspection Form:subsurface Sewage Disposal System page 7 of 17 t5ms•11/10 I Commonwealth of Massachusetts Tale 5 Off ial Inspection For Subsurface Sewage Disposal System Form - Not for Volunta Assessments Property Address owner Owners Name �1,,•�, / l /� information is I-- 6 �•C. -< �oZ requited for every v J State Zip ode Date o Inspe 'on page. Citylrown D. System Infonbation (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: 7"- ` 4 l.� 'F'`✓J Source of information- Was system pumped as part of the inspection? ❑ Yes LSO If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S em: Septic tank, distribution box, soil absorptio 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 op rator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): ruis 5 offid d lnspoc iw Form:Subsurface Savage Disposal System•Page 8 d 17 t%%•tvto commonwealth of Massachu"setts Title 5 ®ffic'i I inspection Form Subsurface Sewage Disposal System Form -Not for Voluntan, Assessments oS Property Address 2 C'4 AV Owner Owner's Name /`information is l/ 00 required for every State Zip Code Date f pectio page. City(rown D. System Information (cont.) Approximate age of all components, date installed (if known and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): `J Depth below grade: feet Material of constructi�40 El cast iron PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of lea age, etc.): Septic Tank(locate on site plan): Depth below grade: feet Mate 'a of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list�agei years Is age confirmed by a Certificate of Compliance?(attacha copy of certificate ❑ Yes ❑ No Dimensions. Sludge depth: J Title 5 Inspedion Form:Subsurface Sewage Dsposal Syedem Page of 17 lsins-11/10 Commonwealth of ssachusetts Title 5 Official inspecti n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26-7s- Property Address ' C� e flL4 Owner Owner's Name r �j informations Q✓1 7�►'1•'t 1 e // � 61 6-71Z required for every page CityfTown State Zip C e Date of i pedi D. System Information (cunt.) 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 baff e o �e -2a C-e How were dimension's determined? Comments (on pumping recommendations, inlet and outlet ee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ,9 • � ✓vim t J,d�� 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 bE ffie Date of last pumping: Date MIS•11110 rMe 6 Official nsvecfion Form:Subsurface sevege of pml System Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for oluntanr Assessme)nts / 0 0/� r✓ Property Address lK Ce Owner OwneYs Name iserr'f -fG✓I/ l r '� /� " O information a- required for every State Zip a Date of I on page. Cityfrown D. System Information (cost.) Comments (on pumping recommendations, inlet and outlet tae 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 in pection) (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: ❑ Y as ❑ 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 cc py attached? ❑ Yes ❑ No Trlle 5 oR ' inspedion Form:Subsurface Sewage Disposal System•Page 11 of 17 (sins•1 V10 Commonwealth of Massachusetts MM Title 5 Official 8nspection rm Subsurface Sewage Disposal System Form - Not for Volunta Assessments Property Address /I(i1CCI Owner Owner's Name ) ���information is �jC -f� (n-` 1.2 required for every State Zip C de Date of I pection Page cityrrown D. System Information (cont.) Distribution Box(if present must be opened) (locate on sitE plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): I/fC/ 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 umps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t%%•11/10 Title 5 Offidal Inspection Form:subsuffam Sevage Disposal Sydem•P29e 12 of 17 Commonwealth of ilAatssachusetts Title 5 ®ffiCial Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address / CI e- Owner Owners Name information is required for every page cityffown State Zip C e Date of I pedion D. System Information (cont.) Type: / leaching pits n mber: ❑ leaching chambers number-. ❑ leaching galleries n imber ❑ leaching trenches n imber, length: ❑ leaching fields n mber, dimensions: ❑ overflow cesspool n mber ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspectio ) (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 t5wm•I/10 Taie 5 official nspec ion Forth:Subsurface Sewage Disposal Sydern•Page 13 of 17 Cq�nmonweaith of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not ttJfor Voluntary Assessments 0 Property Address G� ;'0 A4CC Owner Owner's Name information is CQ✓► l/l // 6 3a ::� /:izo:L required for every Page CgfTown State Zip C e Date of I spedion D. System Information (cunt.) 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.): f5vis•11/10 Time 5 Otficraf nsspedion Forth:Subsurface Sewage Disposal System•P20.14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Volunta Assessments 05 0/d Property Address e_ CCi � Owner OwneYs Namer__c NZvi f information required for every Page City/Town State Zip C e Date of I pe tion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the s Wage disposal system, including ties to at least two permanent reference landmatiics or benchmarks. Locate all wells within 100 feet. Locate ;;her�eublic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Slid.- , EG� q/- Il � f2 `f 3I. �i- �26. - a '� Qy L/ t5ins•11710 Tdle 5 Ofridal I don Forth:Subsurface Sevage Disposal System•Page 15 of 17 i i Commonweatth of Massachusetts InspectionF rm Title 5 Offic•�a Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments � 0_5__ Old- S A Property Address �ltA GG t: Over Owner's Name -,n ' �9 / 1 irrforrnation is N 7�Yt/t / // C/ b �v� required for every Page City/Town State Zip C e Date bf Inspection M System Information (cunt.) Site Exam: ❑ Check Slope Surface water a ❑ Check cellar ❑ Shallow wells rJ Estimated depth to high ground water: 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: ate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Che4gid 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: 4evvi /S I✓lsIlz 1e 2r 11-9)ak1 _J� Before filing this Inspection Report, please see Repod Completeness Checklist on next page. t5ins-11110 Title 5 Official respedion Form:Subsurface Sevage Disposal System-Page 16 of 17 Y CoMmonweaith of Massachusetts Title 5 Official In-spdction Form S,ub�urface Sewage Disposal System Form-Not for Voluntary Assessments PropeFy Address Owner owners Name I information is Gpr►4Q✓ / v,f/ required for every State Zip Code Date of Inspection Page. Cdy/Towrl E. Report Completeness Checklist Inspection Summary: A, B, C, D, or Eichecked inspection Summary D (System Failure Criteria Applicable to All Systems) completed .E3"System Information— Estimated depth to high groundwater 3/S'ketch of Sewage Disposal System either drawn on pa a 15 or attached in separate file Tdte 5 official Iospedion Form:Subsurface Sewage Disposal System Page 17 or 17 t5ins-11110 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: -705 Old Stake Road's Centerville. MA 02632 Owner's Name: Bob Morawski Owner's Address: 38 Park Avenue East Bridgewater, MA 02333 Date of Inspection: April 20, 2001 Map: 191 Parcel. 174 Name of Inspector:(Please Print) James M. Ford Lot: 8 C f.1D Company Name: James M. Ford R� Mailing Address: P.O. Box 49 . Osterville.MA 02655-0049 APR 6 Z00 E Telephone Number: (508)862-9400 F gARNSTAg� N p EpT. W D CERTIFICATION STATEMENT TD NEpyTN I certify that I have personally inspected the sewage disposal system at this address and that the info ion reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes C ditionally Passes Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: April 24, 2001 The system inspector shall sub. a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and.Comments ; ****This report only describes-conditions at the time of inspection and under the conditions of use at that time:' This'inspection does not-address,how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 705 Old Stage Road Centerville, MA Owner: Bob Morawski Date of Inspection: April 20, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria.described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: ` One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system;.upon completion of the replacement or"repair.,as approved by the Board of Health,will pass. Answer yes;no or not determined.(Y,N,ND)in the for the following.statements.: If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: - Observation of sewage backup or break out-or high static water level in the`distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or..obstructed pipe(s). The system will pass inspection if(with approval of the Board-of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 w Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 705 Old Stale Road Centerville. MA Owner: Bob Morawski Date of Inspection: April 20, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ .. Cesspool or privy is within 50 feet of.a bordering vegetated wetland or a salt marsh 2. System will fail unless'the-Board.of Health(and Public Water Supplier,.if any)determines that the. system is functioning in a manner that protects the public health,safety and environment: The'"system,has`a septic tank.and.soil absorption system(SAS).and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform `. bacteria and volatile organic com ounds indicates that the well.is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 1 N Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 705 Old Stage Road Centerville. MA Owner: Bob Morawski Date of Inspection: April 20, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/s day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone I 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gild. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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 . A Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 705 Old Stage Road Centerville, MA , Owner: Bob Morawski Date of Inspection: April 20, 2001 _ 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 backup? i.,. . :._ p Was the site inspected for signs.of break out - - _ . r ✓ ;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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 705 Old Stage Road Centerville. MA Owner: Bob Morawski Date of Inspection: April 20, 2001 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 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2000- 19 000 gals.; 1999-31,000 gals. Sump Pump(yes or no): No Last date of occupancy: Weekend use CONEAERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 1999-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system cesspool Single g Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative,/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source-of information: ... ... ... _..__..... "Ju1y"9"1980 per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 a Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) Property Address: 705 Old Stage Road Centerville. MA Owner: Bob Morawski Date of Inspection: April 20 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete metal _fiberglass polyethylene other(explain) If tank is metal list age: _Is age confirmed by a Certificafe of Compliance(yes or no): (attach a copy of certificate) �_. . . r, Dimensions: 1000 gal. Sludge depth: 1" .. Distance from top of sludge to bottom of outlet tee or bade: 31" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Scum and sludge were minimal. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage;etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 705 Old Stage Road— Centerville. MA Owner: Bob Morawski Date of Inspection: April 20, 2001 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 _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ . (if present.-must be opened)(locate on site plan) ..._.._ .. _ ..._.T.!.L..,_.._.. Depth of liquid level above outlet invert: Even 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.): The D box was level There were no signs of leakage or solids. The D-box was 20"below grade. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM-INFORMATION (continued) Property Address: 705 Old Stage Road Centerville. MA Owner: Bob Morawski +' Date of Inspection: April 20, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'w/]'stone(per septic plans) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow.cesspool,number: _.. ._._hinovative/alternative system _Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,` etc.): The pit had 6"ofwater on the bottom. The scum`line was 4'up from the bottom. There were no signs offailure:. The bottom to grade was approximately 9'. The cover was 2'below grade. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 705 Old Stage Road 74. Centerville, MA Owner: Bob Morawski Date of Inspection: April 20, 2001 Map: 191 Parcel: 174 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 8 Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 13 s3 iiV a 6i - a6 c� 3 Aa- 8 , g.A- a� N3 ay , a3- 3y y Ay. 31 10 Page l l of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 705 Old Stage Road . Centerville, MA Owner: Bob Morawski Date of Inspection: April 20, 2001 SITE EXAM Slope Surface water Check cellar . Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom ofthe leach pit to grade was approximately 9' Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 30'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 y No.....ve_.Z2.� vA..-t Ir F ram.' Fis..3. .... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w..p..............0 F.....�5 ................................ c.. Appliratioaa for Uhipoii al Workii C ow4rudion ramit Application is hereby made for a Permit to Construct (,4�-or Repair ( ) an Individual Sewage Disposal System at: ff....2Qia ......... o .:.r ....... .---�K.----9.7a......P�x-.._.s�?�_-.-.... cation-Address p�� or Lot No. ...............................................t .KtSl�7l •.... !!d k/...K ��.[.......malt................................... Owner Address ------------------. ► s i-------------------------------- ...................------..................--------------------------........-----...........---- Installer Address Q Type of Building Size Lot_,.$0-AL-5.......Sq. feet U Dwelling—No. of Bedrooms............ ............... .....Expansion Attic ( ) Garbage Grinder (/v 6) ............... No. of ersons__-..-_--.._-__________.--__ Showers — p`�,,, Other—Type of Building ............. p - ( ) Cafeteria ( ) a' Other fixtures ............................ W Design Flow......:...... .. ..................gallons per person per day. Total daily flow-----------------33®.............gallons. Al WSeptic Tank—Liquid capacity.-_gallons Length.__...-------- Width--__,.`9....... Diameter---------------- Depth_.. . x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....._...�...-._... iameter.......0___........ Depth below inlet....CP.......... Total leaching area. 0....sq. ft. Z Other Distribution box (i' ) Dosing tank ( ) _� qe� Percolation Test Results Performed by..___._ :C. X _-. _ .•------•.--.._ Date....4..._.�.�.J__......... _ . ,.a Test Pit No. 1�_�-__.minutes per inch Depth st Pitl�.... Depth to ground water -✓'.. - 4q Test Pit No. 2................minutes per inch Depth of Test Pit--- ..2.�... Depth to ground water.. V.CK! _7U. a+' - --- O A -------- escr ton o ----- . � 1 x i .... . I. .V. -----1aj. .4 5"d. .---------------------------------•----------------------------------------------------------------------------------- w - ---------------------- --------------------------------------------------------------------••-----------------------------------------------------------------------------------------......--•••- U Nature of Repairs or Alterations—Answer when applicable._...................................................................................._.......... ------------------------•--------------------------------...--------•---....---------------------------•-•......•--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT LE, 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 th� ar of health.Signed -------••----•...-•--•---•-•• ...._s 91� ...•••••. i D e Application Approved By....... ......'..... -------------------------------- ----•--- _'10------------ Date Application Disapproved for the following reasons:......... ......C. . ...... .......... .. .......................................... .....................................••...._..__...•-••-••-•--------••-••-••-••-•---•...-•-----•- Date Permit No............... Issued..... " -. ..................... No. .-. 2 `a Fxs.. .g�....yl.... THE COMMONWEALTH OF MASSACHUSETTS JBOAR® OF HEALTH Qw.P..............OF.........!'�i�..........S.r ...OL.. _................................... Appliration for Dhipaii al larks (nnnitratrtilan rrr.mit Application is hereby made for a Permit to Construct (4-)-or Repair ( ) an Individual Sewage Disposal System at: J------..--� nr1>?iau k-..-A .........40-r..a-------�°� ....3g ' .---•-- .s...,�'`�..-..--- ocation-Address or Lot No. Q'A � ............ U7�..fi n�0...---....VV.5...-------•-------------------------- Owner Address a ........... ---•-•-•-••----•-moo S ............................... ------•-------------------••----------------•--•---•-- Installer Address UType of Building Size Lot1_,Gy_4f._S........Sq. feet �-, Dwelling—No. of Bedrooms._.__._._.. ...........----------------Expansion Attic ( ) Garbage Grinder (1+0) Other—Type of Building ___-_-__--__•--------------- No. of persons___--__--------_--___-___-__ Showers ( ) — Cafeteria ( ) dOther fixtures .........---•----•--•---------------------•--..••..-•.._.....--------..._.......-----•--..._...---------•-------•----------- W Design Flow................... gallons per person per day. Total daily flow----............2aq.............. lonsll g � ------------------g P P P Y• Y WSeptic Tank—Liquid capacity.&�_-gallons Length____7_........ Width___.,T7......... Diameter________________ Depth.. '!�ca. xDisposal Trench—No..................... Width.................... Total Length---____----._ Total leaching area...a..�__,.:._,...:_-----sq. ft. Seepage Pit No________ _________/Diameter._....E3........ Depth below inlet__.. ..__....__.._. Total leaching areap....sq. ft. Z Other Distribution box (�' ) Dosing tank Percolation 'test Results Performed by......W 1.O,_N�..`:.'a y ��^'..--..-.•..--_-'Date....b ........................ �-7 , L.&L)L-Y, I L Test PiY No. 1 ..'s ---mmutes per inch Depth o Test Pit----- _ ,..._____ Depth to ground water.................. ..... 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------1.._ ------ Depth to ground water C7 V Z 1 a ..............................................................•--•- -- •... xDescriptionLof Soil....... l •.•eveL...-•�� - ' j_Lrs-A.0 - •-•----G.�. -----1..G� k/�'� 31� .,,,.-----------------------•-------------•--------------------------....-----------' -------------------------------------------------------------------------------------------------••------------------------------------------------------------------------------------------------- U Nature of-Repairs or Alterations—Answer when applicable------------------------------------------------•--_-_____----_-.-____-_--_-_-_-_-------------. . •----•--••••••--•-•---------------------••-•--........-•--------••----•---••-•-•---•--•-----•-•---•-••------......--- Agreement: The undersigned agrees to install the aforedescribed .Individual Sewage Disposal System in accordance with the provisions of I i p 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 6tb Oar of health. �� D to Application Approved By........... -- �.a-�!�:.--� � �'---------- Date Application Disapproved for the following reasons:.... • -E = ------------------------------------------ • ------------------------------------------------------------------ Date Permit No Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH EGG?l! T . ....................OF.... .......................................... (9rrtifiratr laf TlantpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed �/) or Repaired ( ) by . . ..a -------•---•-•----------•------•----------------••-------•-------------------------•----•----.----•---•------------------••-•----•-----------.----------------------- Installer at...... --- ...... i-------- ---------------•----------•----•-----------•-------------------........--- _ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..80e!' . ................ dated-_-...__.___._________.____..__._.....___.._._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATI?.... (r..•[•- . ---------•----------------.......... Inspector------ C r THE COMMONWEALTH OF MASSACHUSETTS rah BOARD OF HEALTH '''•�� o 0 L L (1.1,�,f. .......... OF....... / . ..... 7, z.> ..........................................: ,�...�.�.. .... FEE........................ � Disprniial 10orkv Tv"notrnrtilan pamit Permission is h-reby granted------...ZZ -e4----------•---•--•-----------------------------•-------•-------------------.-..-.----------------------------.-•--- to Construct 'f or Repair ( ) an Individual Sewage DisposaU, st 4e. Street as shown on the application for Disposal �NVorks Construction rmit No..................... Dated.......................................... r 4. / . Boar of Health DATE------ l �rL ..........--•--.....•-- '` FORM 1255 HOBBS a WARREN. INC., PUBLISHERS t� r tG►-11 DA-F A. FLCUW t Ib 4 $ t �3D G.p•D. .ell E:PTIG Th+-ttC = 330.r Ir7C•% * 4-qS Ei.Pl7. USC--- l oob 6A,I_. •DISPO54.L PIT - uSE. l Ooo G.o-t- . ' tlj)E.WAI.L AeFa. = (50 S.F. 1G�c > SF--, x 2..S. = 1S G.P.D. �.v4 $csf" C)AA y�. ► .o = So S.R D. TOTAL 'fl ES16Kl = 42S k- mr, -r-o_.r&L_ ca\��r FLvw = 33D 6.PD t�. 45 `7FI�f1CDL&.T1C)tJ 2hTE CIOSMIU• orz � o 1 , A Lu.ARtf G k�. s t ` �d �4 91ST L Fi Y E `) ts33A �< Ro - &A) 1 I o 'co TeST ,i ,'� Tor Fwv I00.O Co�9M r f 'Box q 6 Sc-Qr'Ic t o - s,�tiay wv. 7-AwK 1000 `r4`o 1uv , GQAvFL SAL. . \uv.96`y i. --yho - LeAr-H PIT , • VC/1 TN ' WAf►1ED I•O 1 �.o. � �I _ FgzoP-t C t_E=-- 1 F 37t 5p V)U. /Z.o ,(� ►.�o SGAt_�- SCAT-t= �= CCj' �iATt---_ �� No wR t5,71 I C m tz-r I t= 7 t-t A T T 14 9\N EU , 5 N ►.1 PL A t,1 R r F��c�.I GC t•••IE.�(ci�i�1 CC:x�rlr'1-`!S �,�/ ITI•� TI-1` �jl D� l_it-.tE: ��► Atiit� SC`1-L!,ACV V'CQUIQEAAcuTS of TNC. �L 1C Z-"7 7- , .3 tzaC, tL-[ZIED 1-Awo �U2vi:.`(otZS CA-4 pN USTE�'�/1l.LL U I�A6S , T 1-11`:� C7 t_A►-! 1�.-, �UT SAS EC7 t1 ZrrC:J.✓1�=tJ i �iclt;�/l �' • �(11f vet yt=('s, !yt 1Gl:JLG AP11L.1 CA! _I'T__ ,JCj�•� 1.� �� r�.V l.. f CI_ U=L ri.) i7 Mtt�l-=