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HomeMy WebLinkAbout0049 OXNER ROAD - Health 49 Oxner Road Centerville P A = 193 124 No. 4210 1/3 ORA PendaflexO � 10% 14 V a y n� i �1 F � �pp � r No. _�G ^t `'1, Fee C/ THE COMMONWEALTH OF MASSACHUSETTS Entered incom uter: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9iplitation for his oral *pstrm Construction permit Application for a Permit to Construct( ) Repair(! upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. A�•er Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 17c��S1c�S A 13 iNC 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) oNlx 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. igned Date Application Approved by Date Application Disapproved by Date for the following reasons v Permit No. C�0/ C I Date Issued z— j ' 1 No. �G ` Fee v v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pprication for his oral 6pstrm Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Q x A)pC Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ��'j — L �QC-OWC,or Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. OOS10% A i3 rowN I.nx Type of Building: *, d 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) P lq iG C -e - ► CPC ON I 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 Boar ealth. / �/ Signed (5 " / Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 'DO/4j 1 Date Issued L 1 ----------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS j Certificate of Compliance THIS IS TO CERTIFY,that the On-site ee-SSewage Disposal system Constructed( ) Repaired(Upgraded( ) Abandoned( )by vlcl�_ S A 1�6b�N �N� at H �Nj Pfv�)1 '� has been constructed in accordance I ) with the provisions of Title 5 and the for Disposal System Construction Permit N_�" ^� dated Installer G 5l� Designer #bedrooms Ai I Approved design flow 4 , gpd, The issuance of thin711f ? it shall not be construed as a guarantee that the system will:functionFas desi ned. r� ,� 1 P ff g Y g jn t�{ // 1 /R Date f,a f Inspector '! "( , r ..� ? !I l,i;l � f f?� t y 1 �✓r a. • vv- t --------------------------------------------------------------------------------------------------------------------------------------- No. I L 1 �� r rx)x ON l y Fee /0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction jermit Permission is hereby granted to Construct( ) Repair( V� `Upgrade( ) Abandon( ) System located at qC� C) K N E.�(� C 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:Constructiio,,nJ ust bejornpleted within three years of the date of thisEbyl!L Date ` I I ` Approved r4 °FI„FT° Town of Barnstable Barnstable ti � Regulatory Services Department "lll-AmedcaCity * BARN. ABLE, + I B 9Q MASS. $1639• Public Health Division "O 1m prfD MAl A 200 Main Street, Hyannis MA 02601 2007 SECOND NOTICE Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 2750 March 10, 2014 Mr & Mrs Brian Eacobacci 49 Oxner Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5. The septic system located at 49 Oxner Road, Centerville, MA was last inspected on 8/19/2013, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) Due to the following: • Distribution Box needs to be replaced. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Sample Conditionally Passes\49 Oxner Rd cent Sept 2013.doc CC: Barnstable Department of Health and Environment QASEPTIC\Sample Conditionally Passes\49 Oxner Rd cent Sept 2013.doc �j,W, Town of Barnstable Barnstable Regulatory Services Department ""' 't * MAS& Public Health Division IIIV 200 Main Street, Hyannis MA 02601 2007 SECOND NOTICE Office: 508-862-4644 FAX: 508-790-6304 Thomas F.Geiler,Director Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 2750 March 10, 2014 Mr & Mrs Brian Eacobacci 49 Oxner Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5. • The septic p c system located at 49 Oxner Road, Centerville, MA was last inspected on 8/19/2013, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) Due to the following: • Distribution Box needs to be replaced. You are -ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH '�:oAascKean, R.S. CHO Agent of the Board of Health • QASEPTIC\conditionally passed\49 Oxner Rd cent Sept 2013.doc https:Htools.usps.com/go/TrackConfirmAction.action?tRef fullpage&tLc=1&text28777=&tLabels=70121010000028512750 Ilk �t English Customer USPS Mobile Register I Sign In Service uss.111 0m, Search USPS.com or Track Packac Quick Tools Track Ship a Package Send Mail Manage Your Mail Shop Business Solutions Enter up to 10 Tracking A Find Find USPS Locations Buy Stamps Sct I F Tracking HavequCustomer ServWe'r Cal ul t ¢¢ Have questions?We're here to help. Loo p I Co -- Hold Mail ........ 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CopyrightL?2014 USPS.All Rights Reserved. https:Htools.usps.com/go/TrackConfirmAction.action?tRef=fullpage&tLc=1&text28777=&tLabels=7012101000... 4/1/2014 E Town of Barnstable Barnstable ��OF TF4E Tp�� ° .Regulatory Services Department ;edcac 1 M^ Public Health Division bS9. aim 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010.0000 2851 0053 September 11,-2013 Mr & Mrs Brian Eacobacci 49 Oxner Road - Centerville, MA 02632 • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE TITLE 5. The septic system located at 49 Oxner Road, Centerville, . MA was last inspected on 8/19/2013, by James D. Sears, a certified septic inspector for the State of Massachusetts.. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) Due to the following: • The Distribution box needs to be replaced.. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH omas McKean, R.S. CHO • Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\49 Oxner Rd cent Sept 2013.doc ' Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner information is Owner's Name required for every Centerville page. cityrrown Sae —02632 8-19-13 Zip Code Date of inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information on the computer, g\`�� Uu11f1pU ��� use only the tab ��� 1 Ins p'� a LI �`�`����H of M Inspector key to move your � I ���y�`�,.•••••• _s9 cursor- not James D.Sears �o:• O use the return yreturnJA M E S m key. Name of Inspector CapewideEnterDrises,LLC �I Company Name ''�����i I N SP��'O``��`• 153 Commercial St. �I Company Address Oi 5 Mashpee City/Town MA 02649 508-477-8877 State Zip Code Telephone Number S1623 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 spedor's Signature 8-20-13 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 U v Title 5 Offidal tnspedion Form: Sewage Disposal System•Page 1 of 17 -� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owners Name information is required for every Centerville MA 02632 8-19-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than.20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Tice 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville AAA 02632 8-19-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): Need to replace D Box ❑ 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•3N3 Title 5 official Inspedim Form Subsurface Sewage Disposal System•Page 3 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville .MA 02632 8-19-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (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 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 looMM is less than 6"below invert or available volume is less than%day flow ,0/7- t5ins•3M 3 Title 5 Official hapection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owners Name information is required for every Centerville MA 02632 8-19-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes N 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 p gg copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section.D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville MA 02632 8-19-13 page. Clty/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)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner owner's Name information is required for every Centerville MA 02632 8-19-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal tank D Box and pit. Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2011-59,000Gals 9 ( y g (gp ))' 2012-44,000Gal's Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: Present 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•31 3 Title 5 official Inspection Form:subsurface Sewage Disposal system•Page 7 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner information i Owner's Name s required for every Centerville MA 02632 8-19-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2009/2013 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-3h 3 Title 5 Official hspec im Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville MA 02632 8-19-13 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: 1981 Permit 81-313 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"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 and SCH 20. Septic Tank(locate on site plan): Depth below grade: 10"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal.Precast Sludge depth: 1" t5ins-3/13 We 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 + commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b` 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville MA 02632 8-19-13 page. cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" 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. In and outlet tees. No sign of leakage or over loading. 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•3113 Tft 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name i information is required for every Centerville MA 02632 8-19-13 Cfty/Town page. State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville MA 02632 8-19-13 page. Cityfrown 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 16"x21"-14"below grade w/one line out Wall's are gone on box. Need to replace D Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *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•3M 3 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner owne information is required for every C r's Name enterville MA 02632 page. CityRown 8-19-13 te Zip Co ed Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative 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/2'stone. Pit and cover at 30"below grade. 40"water in pit. No sign of over loading or solid carry over. No high stain line. 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 t5ina•3/13 Indication of groundwater inflow ❑ Yes ❑ No Title 5 official IMPeaion Fort:Suysurtaos Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts lugTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner owner's Name information is required for every Centerville MA 02632 8-19-13 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 lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville MA 02632 8-19-13 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 o1v7. .18 A 13 94 ❑ R-3 = 33 -7 D X /V le t5ins•3113 Title 5 official Inspection Form:Subsudece Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville MA 02632 8-19-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water: 13'-6" 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: 6-2-81 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: T.H. on design plan 6-2-81. No G.W. at 13'-6. Bottom of pit at 8'-6" below grade. Bottom pf pit at 5' above T.H. Depth. Before filing this Inspection.Report,please see Report.Completeness Checklist on next page. t5ins•3/13 Title 5 Oficiai Inspection Forth;Subsurface Sewage Dlsposaf System.-Page 16 of 17 . i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 49 Oxner Rd. Property Address Danielle Eacobacci Owner Owner's Name information is required for every Centerville MA 02632 8-19-13 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMOTNI T�VEA ,TH OF Al SSACHTC SE 1 TS Y ' EkECtiTNE OFFICE OF E�Z?RO--1 TE\T_a _ rF_zRS =, DEPARTMENT OF ENWRONT ENT-A-L PROTECTIO-\ /Y1 �,� i9j la I/ TITLE 5 OFFICIAL, I\SPECTIO\ FORM—NOT FOR VOLUNTARY ASSESS-MENTS SUBSURFACE SE«'AGE DISPOSAL SYSTEM FORM PART A 1, .F f /a'I�/, CERTIFICATION Q l Property Address:_ 0A4e,,- � J O-,,ner's Name: C 0� owner's Address: G a tr Date of Inspection: \ame of InspectoiL,�ase print) c:3rCompany \ame: k-14 -Mailing Address: Telephone Number`-6-VO CERTIFICATION STATE-IN7ENi' I certifythat I have personally inspected the sewage disposal system at this address and that,fie morn ation repo ted below is true; accurate and complete as of the time of the inspection.The inspection v,as perff- ed based or, 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 1-5.340 of Title 5(310 CNIR 15.000). Tle sy s.er_:: C, �Passes Conditionally Passes Needs Further Evaluation by the Local Approving Auth:D--: Fails Inspector's Signature: Date: T he system inspector, shall submit a copy of this inspection report to the 3ppro;in; _ utho--:(Boa-d o< I: DEP)within 30 days of completing this inspection.If the system is a shaved st-steu_or has a des<_- _Nor, of i0_s rr; apd or greater, the inspector and the system owner shall submit the report to the app-npriate -regional, o f"ce of the DEP. The original should be sent to the system owner and copies sent to the buy er. i_ applicable, and auuhorty - - Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use at tLhar time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title Inspection Form 6l15i2000 Page 1 ~ PaQe 2 of I I OFFICIAL INSPECTION FORTH—NOT FOR VOLUNTARY ASSESSIfE\TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR_ PA-RJ'A CERTIFICATION (continued) Property-Address: l 9 X!�Q e 14- Owner: Pd1 /' C o Date of Inspection: e Inspection Summary-: Check A,B,C.D or E/AL«_4.YS complete all of Section D A Passes: I have not found any information which indicates that an of the failure crl'te-a described 310 C\_fR L.303 or in 3I0 CMR 15.304 exist.Any failure criteria not evaluated are i,-udicated below. Comments: B. System Conditionally Passes: /y One or more system components as described in the"Conditonal Pass":ecaon need to be replaced o_ repaired. The system upon completion ofthe replacement or repair,as approv ed by t' e Board o=rrlea:th. ;?iI na;s Answer yes, no or not determined(Y,\t,\D)in the for the following statements. If"not de-re Tease explain. - The septic tank is metal and over 20 years old,or the septic tank(whefner metal or not) is -.tc-mra±ly unsound, exhibits substantial infiltration or exfiltration or tank ailure is iinminent. S.stern v, pass ins_;;ect;on'1 Lne 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 i f a Ce_:i_icate of Cor pll, c indicarng that the tank is less than 20 years old is available. "�D explain: Observation of se'kvage backup or break out or high static Nvater level in the diszbu- on bot_due o broker e_ obstructed pipe(s) or due to a broken, settled or uneven distribution box. S-steun will pass inspector_if -=h approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ",D explain: The system required purnping more than 4 times a year due to broken or obs n cze pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed \D explain: Pare_ of 11 OFFICIAL INSPECTION FOR1v1-NOT FOR VOLUNT-�RY ASSESSIIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN'SPECTION FORM PAkCY Q CERTIFICATION(continued, Property-Address: Owner: 720 C✓i c ,f m tI Date of Inspection: Q C. Further Evaluation is Required by the Board of Health: Conditions exist w1luch require further evaluaron by the Board of Health in order to dere:. -?ne if is failing to protect public health; safery or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 1-4.303(1)(b)that the system is not functioning in a manner which will protect public health. safety and the en«ronment: Cesspool or privy is within 50 feet of a siuface water Cesspool or privy is within 50 feet of a bordering vegetated ivetiand or a salt marsh 2. Srstem will fail unless the Board of Health(and Public Water Supplier,if any) determines that the s-,'stem 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 _ - 'OG feet of a surface water supply or tributary to a surface water supz•ly. The system has a septic tank and SAS and the SAS is within a Zone 1 of a nubli: ::ate-sunpl_:. _ The system has a septic tank and SAS and the SAS is, ithin 50 f.,..t of a priv?:e vale-su-n ell. _ The system has a septic tank and SAS and the SAS is less than 100 fee-L but f0 feet or mo-e from a private water supply well"". Method used to determine distance "This system passes if the well water analysis,perfo_--ed at a DEP cent led_abo-a-o_ fo_core- bacteria and volatile organic compounds indicates that the iyell is free from t~ollution=e-r_that facili-:a_d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 failure criteria are triggered.A copy of the analysis musi be attached to this _o= 3. Other: Pa(ye 4 of 11 OFFICIAL INSPECTIOI FOR-,NI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATIO\ (continued) Property Address: Owp_er: Pv!G/r Jo Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or"no"to each of the folloRdrq for all insneetions: Yes No Xach-up of sevvaae into facility or system component due to overloaded o.clogged S_zS or cesspool _ ( Discharge or pondinQ of effluent to the surface of:he around or surface,, aters aue to an ov erloaded or -/ I ogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged S_3S cr cesspool Liquid depth in cesspool is less than 5"belo-,v invert or available vol ume is I e S 5 thnan / dad.- o: equired pumping more than 4 times in die last year\OT due to cloagee or obs-ucred pipets'! <mbe_ of limes pumped VVVVVV .v portion of the SAS, cesspool or privy is below lsan ground rater e.evaro . _ An%porton of cesspool or pricy is within 100 feet of a surface eater suppl-v or nbu,ar7.to a :surface water supply. _ —V-/4; r portion of a cesspool or privy is within a Zone l of a public R e_l. nv portion of a cesspool or pricy is within 50 feet of a private water sup ly'Fell. An% portion of a cesspool or privy is less than 100 feet cut o-eater than=0 feet=om nri�-a:e 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,proxided that no other failure criteria are triggered. A coPy of the analysis must be attached to this form.] f (Y'es;N o) The system fails.I have deterrrlined that one or more of the above fail-Li:e c_i.eria exit as described in 310 CNIR 1 .30 3.therefore the system fails. The sysTern o.: er sr;ouid coniact the Board Of Health to determine what will be necessary to correct the failure. E. Larae Systems: To be considered a large s-,-stem the system must serve a facility-with a design flow of 10.000 2pd to 1=.000 apd. You must indicate either"yes"or"no"to each of the foliovim�: (The following criteria apply to large systems in addition to the criteria above) �'eS it the system is within 400 feet of a surface din-rang water suppl. the system is v%,ithin 200 feet ofa tributary to a surface drLi�g water Sup:.`:,.` the systemTiis located in a nitrogen sensitive area(Inter _t ellhead Protec ion_�__ea-I` ?_-'.) one lI of a public water supply-;yell if you have answered"yes" to any question in Section E the system is considered a si ficant..h-ea o_ eye es" in Section D above the large system has failed.The o:ner or operator of an, la-a:- ; _te": : :-;iue_�d significant threat under Section E or failed under Section D shall upgrade the sv-K ^tic c o-Gan 1 f.304. The system owner should contact the appropriate re?ionaj office of The Denarent. rage -5 of 11 OFFICIAL INSPECTIO-'FORM-NOT FOR VOLUNTARY ASSESS:IENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA P_A-RT P �{ CHECKLIST Property Address: / O���V (� Owner: ll`eo r f G S o ", Date of Inspection: (/J, Check if the follow- n-have been done.You must indicate"ves or"no` as to each of the `o?c.vi a: Pumpina information was provided by the owner, occupant; or Board of Health -- �V-ere am of the system components pumped out in t;'ie previous:-vv o r,ezk-s Has the system received normal flows in the previous n:o week:period fve iarae volumes of water been introduced to-he system recent!!v or as par i of f=_is _s ec on? f `mere as built plans of the system obtained and examined?(if then-,vere not available_,e_e as Was the facility or dwelling inspected for suns of sewage back up ? f Was the site inspected for suns of break out Were all system components; excluding the SAS; located on site ? r/ ere the septic tank manholes uncovered;opened, and the inter=or of,he:ar_k i_spec-ec for the con -on of the/baifle.s or tees. material of consmrction dimensions;depth of liquid; depth of sludge and depth of '\Vas the facility ovzner(and occupants if different from owner)prop ded v- th o_ a or on the proper maintenance of subsurface se"-age disposal systems' The size and location of the Soil Absorption System(SAS)on the site has bee-n det:- ~--d�a_td on: 1es/ro /!// Existina information. For example, a plan at the Board of Healih. v Determined in the field(if any of the failure criteria related to Part C is a i_sue arr :i -o-of is unacceptable) [3-310 CMR 15-3302(3)(b)] Pa`e 6 of'_1 OFFICIAL I\SPECTION FORA—NOT FOR V OLU TARY ASSESSIIEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM paRT C SYSTEAI ITT TOR1ILATIOti Property Address: P/� ✓v�Ile, ��i� Ocs-ner: ,,cj, o Date of Insaection: ? FL W CONDITIO-S -�� ✓f RESIDE\�TI_=�I.. Number of edrooms desi�z : b ( �-) � \umber ofbedrooms(actual): I DESIGN flow based on=10 CN. 15.203(for example: 110 gpd x=of bedroor^n-): �a O umber of current residents: 0 -7 Does residence have a garbage grinder(yes or no): is laundry on a separate sewage system(yes or ro)�/E'� if s es separate inspection recu ed' Laundry system inspected (yes or no): /66 A Seasonal use: (yes or no):_�� /`✓C �-vater meter readings, if available(last 2 years usage(gpd)): Sump pump (yes or no): *,0 ! Last date of occupancy: 6 � /it�► T COMMERCI_UIN7D STRIAL Type of establishment: Design flow("based on 310 CvrR 15.203): opd 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):_ ater meter readings, if available: last date of occupancyhtse: OTHER(describe): GENERAL I\FOR�"ATIOi' Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If Yes. volume pumped: gallons--How vvas quantity pumped determined? Reason for pumping: TYP SYSTEM Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Pri,,z Shared system(yes or no) (if yes, attach previous inspection records. if any) i 2no vari e/Alternative technology. Attach a copy of the cu,ent operanon and ma me =-ce C- — - :'L' 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 rLo: "'e_ri: l �/— O� Were sewage odors detected when arriving at the site(yes or no): T:-]o 6 Pacre ?of 11 OFFICIAL INSPECTION FORI FOR VOLU\NARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEI?INSPECTION FORM P.111R.'r C SYSTEM INFORNIATION(continued) Property Address: Q� Rd Owner: lq2d1 /1 G Stp 0 Date of Inspection: BUILDING SEWER(locate on site plan) Depth below Grade: /,/? Materials of construction:_cast iron _ PVC_other(explain): Distance from private eater supply well or suction line: Comments (on condition of joints; venting,evidence of leakage, etc.): SEPTIC TANK: �(locate on site plan) Depth below grade: /O Material of construction:_ one ete_metal_fiberglass youlyethvlene other(explain) if tank is metal list age: _ Is acre confirmed by a Certificate of Compliance(yes or no):_(a.rach a copy of certificate) Dimensions: S'udge depth: y Distance from top of sludge to bottom of outlet tee or baffle: d Scum thickness: l`oZ ii i/ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of utlet tee or baffle: How were dimensions determined: d"o le C16 viCP Comments (on pumping recommendations.inlet and outlet tee 6-baffle condi ion. sLacraral intent . liauid ieyels as lated to outlet invert., evidence of leakage. . ): GREASE TRAP:��ocate on site plan) Depth below grade:_ Material of construction: _concrete_metal_fiberglass coivethvlenp er (e:plain): 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 baf:Ie condition_. snacrL:ra? as related to outlet invert. evidence of leakage;etc.): Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Y AWr C SYSTEM INFORMATION(continued, Property Address: Ov.-ner: �7`�dt i� lvso✓7 vi 2 Date of Insnection: t� d 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(.explaiia: Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): alarm level: Alatrn in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,etc.): DISTRIBUTION BOY: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 011�`7 Comments (note if box is level and distribution to outlets equal, an-,.-evidence of solids car.over, anv of leakage into�9.r out of box. exc): J 0 X e4'-e-,/, o PI NIP CHAMBER: /1� (;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 appurtenance_, Pace 9 of l 1 OFFICIAL: IINSPECTION FORN-T-NOT FOR VOLL--NTARY ASSESSMENTS SUBSURFACE SEN1 AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORALkTION(continued) Propert_ti-Address: Ll YnX /I gc' e� v e 11 Opener: ��� /! c Sifl Date of Inspection: Qom(, SOIL ABSORPTIO\ SYSTE I(SAS): (locate on site plan, excavation not required) if SAS not Iocated explain why- T�-p "X 6 leaching pits. number: v leaching chambers, number: -JZO t17 leaclhing eal'_eries. number: leachin'a trenches, number,, length: ieachinu fields. number. dimensions: o�°erflo-cesspool. number: innovative/alter ati--e system Type/name of technology: Comments (note condition of soil; signs of hydraulic failure,level of pondilzg, damp soil, condin on of v eQetation; etc. r G G 1 CESSPOOLS: &"(-Cesspool must he pumped as part of insnection)(locate on site plan_; \umber and configuration: Depth-top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow. (yes or no): Comments (note condition of soil signs of hvdraulic failure. level of pondincr, cone�o PRIVY:kloocatte on site plan) ) Nlateriais of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs ofhvdraulic failure, level ofponding, ccndi=on c= --,-. 9 Page 10 of 11 OFFICIAL INS PECTIO\' FOR7k'T--,N'OT FOR VOLUSTARY ASSESSMENTS- SUBSURFACE SEWAGE DISPOSAL: SYSTEM INSPECTION FORM P A'T C SYSTEM I\FORti'TATIO\(co nt~ ued) Property Address: / G x nP,,-- u ON-,ner• c 5��1 Date of Inspection: Q SKETCH OF SENVAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to a:least t�z,o pe, ~a?enz referee e is_id__arks cr benchmarks. Locate all u elis xvithin 100 feet. Locate where public water supple enters the uin `s r tom% R 0 ��I— t fe✓ _.1 g,, 33 i Page 1 I of 11 OFFICIALT INSPECTION FORMM-\OT FOR V-OLFI�TARY ASSESS-MENTS SUBSURFACE SEWAGE DISPOSAL SYSTE-M T-SPECTION FORM .P Ikn-r c SYSTEM INFOR'1LATIO (conzurued) Property Address: i CJ- Owner: ��l �n C l.-fy ✓ ���� Date of Inspection: SITE EXA- 1 Slope'. Surface-,eater Check cellar j V� Shallow wells ` O V"^ Estimated depth to ground water feet��• C9� O?lease indicate (check) all methods used to determine the high ground wAter elevation: Obtained from system design plans on record-If checked.date of design nizn re�'ie�ed: Ob ed site (abutting property/observation hole czithin 150 feet of SAS) Necked kith local Board of Health-explain: Checked wZeh local excati ators_installers-(attach dog unentaron) Accessed i�SGS database-explain: You must d crib ow you established the high ground water elevaflo r c, (it C 0 S t9 i 30 iv l 7 L..S7' >�R.�Si�n � TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS �! 4"CAST IRON 12°M7Arlr , PIPE 12"MAX. f EQUIV.) R MIN. 4'ORANGEBURG(OR EQUIV.) PITCH 1/4"PER. PIPE- MIN. LEACH PITCH 1/4"PER.FT. PIT PRECAST NVERT a LEACHING <" EL. •I... INVER]' INVERT o . c�k QI •� PIT OR ° . SEPTIC''TANK ] SZ DIST. w ';c r EQUIV. INVE Tt� Box e; EL► .,1. 1404�..: GAL: INVER,ZA '. G Q: I NVR 3/4"'TO I I/2,' .�� w .� WASHED p,• / w STONE .� �2 6'DIA.F o• /a' DIA.--� PROFi LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE -#P-3gq S I L LOG WITNESSED BY : � - DATE;WP 07- 6//gFlPI4 BOARD OF HEALTH TEST HOLE I TEST HOLE 2 T,�-,.94 G, ENGINEER ... ELEV. ELEV .. .. . . . . . . � LoAM asdi� DESIGN DATA Q �ZFir�oe�D / Sj „/25 1 NUMBER OF BEDROOMS TOTAL ESTIMATED FLOW . .22� . GALLONS/DAY Co�2sc BOTTOM LEACHING AREA 7&•56. . . SQ.FT. /PIT S.MAuC SIDE LEACHING AREA . .�88,�D , SQ.FT./ PIT GARBAGE DISPOSAL (50 % AREA INCREASE) TOTAL LEACHING AREA . �IO�Q.d SQ.FT PERCOLATION RATESS.?�7/�![J,2 MIN/INCH LEACHiNG AREA.PER PERCOLATION .RATE SQ. SQ.FT. / D. .WATER ENCOUNTERED NUMBER OF LEACHING PITS 4rY67 APPROVED . .. . . . . . . : . . . BOARD OF HEALTH Z 71-1•T'�4. 5 7 Q� P-v,6 04 F9L4 SIB S ._ .13;�4 ,5 DATE AGENT OR INSPECTOR G07 8 0X'AJEA4 ram/. o� THO G • ���� ' THOMAS E.KELLEY CO. � � A4 `ENGIINEEgs SURVEYORS 2126o Q y 346 LONG POND DRIVE SO PETITIONER 1 TARMOUTFI•b1.98j{. XAI� 0 2G`3 . . . : . . 02654 frI/ 4, /f9ls/ �b • �� �� i THOME Y MAS °yv o1\'t1 E 424260 � Q /7t t+ O 0 TNOYAS L au� THOMAS E.KELLEY CO. ENGINEERS—SURVEYOT (` 346 LONG POND DRIVE SOUTH YARMOUTH.MM 7 .38 •-: oz664 I IF LOCATION SCALE ./.; .: •+ DATE ! /0/. PLAN REFERENCE .4,07 &- .. ..... . t CERTI T THE<LAND SHOWN ON PLL/.T,4N:S ig�VD ; . AS SHOWN' i. OJ1TPETITIONER: TROY WILLIAMS SEPTIC INSPECTIONS NOV 12 2003 Certified by MA Department of Environmental Protection TOWN OF BARNS T b LL508 385-1300 HEALTH DEPLr 19 Hummel Drive South Dennis, MA 02660 MAP ....,,�.� PARCEL , 4 COMMONWEALTH OF MASSACHUSETTS LOT 3 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION f TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 49 Oxner Road Centerville,MA Owner's Name: Thomas McCabe Owner's Address: 790 Falmouth Road,#132 O Date of Inspection: Hyannis,MA 02601November 10,2003 Name of Inspector: 'Troy M.Williams O Company Name: TroyWilliams s Septic Inspections Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 02660 (508)385-1300 CERTIFICATION STATEMENT 1 certify that 1 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 ['asses Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: I/// /6 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This Inspection represents the conditions of the system on the Date of Inspection noted above. ""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 saute or different conditions of use. Title 5 Inspection Form 6/15/2000 pace 10'r I I Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 49 Oxner Road Owner: Centerville,MA Date of inspection: Thomas McCabe November 10,2003 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 C%4R 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 re ced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of ealth,will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statements. I not determined"please explain. The septic tank is metal and over 20 years old* or the septic tarok(wh er metal or not)is structurally unsound,exhibits substantial infiltration or exfiltratiori or tank failure is i inent. System will pass inspection if the existing tank:is replaced with a complying septic tank as approved by a Board of Health. *A metal septic tank will pass inspection if it is structurally sound of 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 t or high static water level in the distribution box due to broken or obstrt .ted pipes)or due to a broken,settle r uneven distribution box.System will pass inspection if(with approval of Board of Health): ken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The s m required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspe on if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND.explain: k.. 4. 2 Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 49 Oxner Road Owner: Centerville,MA Date of Inspection: Thomas McCabe 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) hat the system is not functioning in a manner which will protect public health,safety and the envir ment: — 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 mar 2. System will fail unless the Board of Health(and Public Water pplier,if any)determines that the system is functioning in a manner that protects the public heait ,safety and environment: _ The system has a septic tank and soil absorption sy m(SAS)and the SAS is within 100 feet of a water ater supply or tributary to a surface waters ply. The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more frort1 a private water supply well** ethod used to determine distance "This system passe the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and vol 'e organic compounds indicates that the well is free from pollution from that facility and the presence ., ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure cr' ria are triggered..A copy of the analysis must be attached to this form. 3. Other: > `xyW. eFs�•`+r r .a}J tt 'is7.'iS, �`.♦ a 4.a, LS ,,.i .ys �ry� ' '+ *,d r. �y r. • _ " � . Y }s k' r "�.,y r r,.., �4.. ft 'r J,' 3"F��"tt��y x , 3 7. r ' Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 49 Oxner Road Centerville,MA Owner: Thomas McCabe Date of Inspection: November 10,2003 D. System Failure Criteria applicable to all systems: You mus 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 ✓ Required pumping more than 4 times in the last year VgLduc to clogged or obstructed pipe(s).Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. NM Any portion of cesspool or.privy is within 100 feet of a surface water supply or tributary to a surface water supply. N13 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 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 forma 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 sx-stem 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 deli flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteri ove) yes no the system is within 400 feet of a surface drinkin ater supply the system is within 200 feet of a tribu o a surface drinking water supply the system is located in a nitroge nsitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water sup well If you have answered"yes"to question in Section E the system is considered a significant threat,or answered "yes"in Section lJ above the ge system has failed.The owner or operator of any large system considered a significant tlul; f undfpr S . ton E or failed under Section D shall upgrade the system inccordattce with 310 CM 15.3Q4.';'he yst M o o should contact the appropriate re$iop i office of tht3 pepartmSttt• s ; 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 49 Oxner Road Owner: Centerville,MA Date of Inspection: Thomas McCabe November 10,2003 Check if the following have been done.You must indicate`yes"or"no"as to each of the following-: Yes No P:;:;Ding information was provided by the owner. occupant,or Board of I Icald, 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: 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)) i 4 } 9 fY� I e Page 6 of I I OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION Property Address: 49 Oxner Road Owner: Centerville,MA Date of inspection: Thomas McCabe RESIDENTIAL November 10,2MLOW CONDITIONS Number of bedrooms(design): 02 Number of bedrooms(actual): a DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x k of bedrooms): Z a Number of current residents: D Does residence have a garbage grinder(yes or no):_YES Is laundn on a separate sewage system(yes or no):^to [if yes separate inspection required] Laundry system inspected(yes or no): vv/q Seasonal use:(yes or no): No Water meter s or n ): available(last 2 yearsLsage(gpd)): v Z= (06 v�u u (,,. y Ol z Sump Pump(ye 7Y�v�o Kl�s., s Last date of occupancy: COMMERCIAL/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 S syste (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION ' Source of information:/Vo n ,N ,,: , _szr_✓.. ,. 6 rt. Was system pumped as pa of to oo he inspection(yes or no): vim„ 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/Altemative 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):. M roximate aee of all components.date ittstalled(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):Ma 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Oxner Road Owner: Centerville,MA Date of Inspection: Thomas McCabe November 10,2003 BUILDING SEWER(locate on site plan) Depth below grade: 18 " f Materials of construction:_cast iron ,/40 PVC ✓other(explain):1; Dkiance horr,private water supply well or suction line: Ai/'9 Comments(on condition of joints,venting,evidence of leakage,etc.): CIA / SEPTIC TANK:_V/(locate on site plan) Depth below grade: p Material of construction: ✓concrete_metal fiberglass,polyethylene _other(explain), If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: _ S'�a 'x 4. ' /000 5�e !/o . Sludge depth S Distance from top of sludge to bottom of outlet tee or baffle: z ' 7'' Scum thickness: a Distance from top of scum to top of outlet tee or baffle: 6 ' Distance from bottom of scum to bottom of outlet tee or baffle: /1' How were dimensions determined: Ew``. _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Ov{ l 4 Tc S t..l:s,i+ 1, t1 T ��-y.f�l,E_J CIL 4 4P-4 W tYl GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass___poly ylene_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 baffle: Date of last pumping: Comments(on pumping recommendations,in and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of le e,etc.): 7 I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Oxner Road Owner: Centerville,MA Date of Inspection: Thomas McCabe November 10,2003 TIGHT or HOLDING TANK: (tank must be pumped at time of inspecti (locate on site plan) Depth below grade:. Material of construction: concrete metal fiberglass olyethylene other(explain): Dimensions: Capacity: gallons Design Floe: gallons/day Alarm present(yes or no): Alarm level: Alarm in working orde es or no): Date of last pumping: Comments(condition of alarm and flo switches,etc.): 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Cotntrtents(note condition of pump chamber,condition of p s and appurtenances,etc.): 5t - 1a¢l4a�g4 FS Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Oxner Road Owner: Centerville,MA Date of Inspection: Thomas McCabe November 10,2003 SOIL ABSORPTION SYSTEM(SAS): ✓(locate on site plan,excavation not required) If SAS not located explain wh): TT leaching pits,number: 1 — kG " Lc 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. ii yy��t.�s � WLr4 T"D✓.�� 0.� 7�s /7M-C p/� ! �+>/ _4iia�. �J CrESSPOOLS: (cesspool must be pumped as part of inspection)(locat n siteplan) s Number and configuration: n Depth—top of liquid to inlet invert: dS'i 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 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 hydraull ilure, level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Oxner Road Centerville,MA Owner: Thomas McCabe Date of Inspection: November 10,2003 SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. V rv'rw R I A e- 90 : 2q ,` pc = 3 3 i 29 I i000i I I f I zi, � I i Page I I of OFFICIAL INSPECTION FO RM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Oxner Road Owner: Centerville,MA Date of Inspection: Thomas McCabe SITE EXAM November 10,2003 Slope v Surface water Check cellar ✓ Shallow wells Estimated depth to ground water ,.33 ' -- feet Adjusted high ground water clevation��. feet Please indicate(check)all methods used to determine the high ground %%ater 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 Ilealth-explain: Checked with local excavators, installers-(attach documentation) ✓ Accessed USGS database-explain: SQ c✓ Z_ L Y S 3. z , You must describe how you established the high ground water elevation: 41 -- — � - 4 --- U Zv .'3 This report has been prepared and the system Inspected 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 �� LIG r' � % �► LOCATION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS R U I L 0 E R OR OWNER , DATE PERMIT ISSUED �, � j / DATE COMPLIANCE ISSUED 0�/se AJ a 1 x � Q a No.f1 ......... ....... Fss.............................. THE COMMONWEALTH.OF MASSACHUSETTS ` BOAR® OF HEALTH ............... .........................OF......-.-.--........-....-...__.... , ppliration for Disposal 10orks Tunstrnrtinn thrutit Application is hereby made for a Permit to Construct (W<O"r Repair ( ) an Individual Sewage Disposal System at: -- ----- --- --- ----- --------------- Location- ddres r Lot NIOwner Addres a ........................ -.�!►.. _._._...........,•------------_.....--•--_---_._ ..................................... ,i�Y-a. :.... .......... Installer Address f"r Type of Building Size Lot._® '$_ppo.......Sq. feet U Dwelling—No. of Bedrooms.__..._11L-. ______________Ex anion Attic '-' p ( ) Garbage Grinde".(---) -- Other—T e of Building p ••-••-•---•---• Showers ( ) — Cafeteria ( ) a YP g ---•------•••--•-•---••--;_. No. of persons Other fixtures W Design Flow............................. oo�.__gallons per person per day. Total daily flow___.____.___.______________._.....-__.......gallons. W Septic Tank—Liquid capacit ____.._.____g ...... Length__$...__.__.. Width-A. Diameter-------_......... Depth.... x Disposal �—No ____________________ Width.._ .._.._._______ Total Length.___Z_______.___..Total leaching area__�d�7..sq. ft. Seepage Pit No................ Diameter.....-.............. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ) �4 Percolation Test Results Performed by--------------------------------------------------------------------------- Date........................................ 1.4 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GG ............................... ---------------------------- 0 Description of Soil_..------•......................•-•--...........-----•--•--•-----------•------------------------••••-----__...... V ......--•------•----•-•-------------•-•---------••---........__...._....-•-•-•----•--•--.....:.__..-•--•-•--•-•--------------•-----------------_..----•--•----•------:.._...----...._•---..----------•--- W x ---•-------••••---------•....-------•----•--•••-•-•------•••-•------••-•-------•---••---...------••-•••----------------------•-----•---•------•----•••-•------•---...:•••--.....-••••••---....--------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...........................................................................----•-••••••-......-----•.........•--•••-----•-••--••-•....-•---••-•-•••-•-------•••---•-••••----•-•-..._•-----•••-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI.L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i u d by e boar of ealth. igned . te Application Approved By - Date Application Disapp ved the ollowing reasons:-----•--------••------••--------------------•----------•--•-•-•••-••---•-••-••-•-- ........................... ...--•--•---------------------------------•---•-----------•--Da.te PermitNo.......................................................- Issued-...................................................... Date .. No..��••---�•�-.� Fps..�.��............... THE COMMONWEALTH OF MASSACHUSETTS T` BOARD OF HEALTH ........ .. .............................OF..........................................-- Appliration for UiipoaFal Work.5tonstrurtion r-rntit Application is hereby made for a Permit to Construct (0 or Repair ( ) an Individual Sewage Dis a1 System at -Location ddress p �y ............... L'.=..:.. d °". ................................. .............. � Lot NqE , ! Owner Addre�W ^' .ems................ .. .............. Installer AddressP+ Type of Building Size Lot.._ ------Sq. feet Dwelling—No. of Bedrooms.._...'_`.:........................Expansion Attic ( ) Garbage Grindep—(—)• p04 Other—Type of Building ............................ No. of persons..... ____-_-------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................................................ WDesign Flow............................. ®_.gallons per person e; day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacit .......---..gallons. Length................ Width to _._._... Diameter................ Depth.�.... x Disposal �Ir—No..................... Width...4...._. ..... Total Length-__<: 4_...... Total leaching area-_+5e P._._.sq. it. Seepage Pit No-_------------ iameter......................Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (h' Dosing tank ( ) aPercolation Test Results Performed bY--------- -------•---••-----•-------•----------•---•-------------------• Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ O19 .---•----••---------------•---------------------...--------•------------•-•-•---•----...---------....-•----•----•-----------•-------•---•------....---•--.... Description of Soil................................................................=...............................-----•---------••----- x V ----•-.......•----••••.........-•-------------••.....-------•--•--------•-----•---••---------••---•----••-•......---••----------•----•--•-•-•---•-•-----••--•------•.....-----------•----•--•--•---•--•. W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ---------------------------------------------------•--_-----------------------------•-----•----.....-•------...-•-•-•----------•---•-•-••---•--•-••---•-•••--.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned urther agrees not to place the system in operation until a Certificate of Compliance has been; d by� e boar, ealth ES ,?,,o , gned, `yc y.. ......... ............. Application Approved BY <.pellowin r" .....-----•-••-------••.•---- ......'.�/ Date Application Disappr ed f o g reasons:-----•------------------- ---_..... -------------------•-----•-------------•--•--------•----•--•--------------•••-----------•-----•.... Date PermitNo--------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS //•���""" BOARD F HEA�- ��/...r'�.-.r�=.^:t....................OF...f; � '&` ........e...... ............................... %rriif iratr of ontpliFanrr T �TO C TI T the Individual Sewage Disposal System constructed ( or Repaired ( ) at.......... ...••. -- I tatter .e�efri-� . . �� f has been stalled in accord ce with the p vi ons of TITLE 5 of The State Sanitary de s des ib�d in the application for Disposal Works Constructi n .ermit No--- _,�1 .............. dated_-. .. ._. ___.__._.._....._._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... � ....................... Inspector..—.�... /. /./-------.-----------•------------------------•--•--- THE COMMONWEALTH OF MASSACHUSETTS BOAR F HEA 4 ......................OF.. .. No.-- ". � .... -../ FEE... ..0............. Dispo �1 works S#r. ` ion rrntit Permission is hV�Rep ' rante .._ - . ..`..._. to Constr t�_ 'r ( ) an '4idual S . rage D' s Syst at No... -2 t ------------- Street r as shown on the application for Disposal.! I rks Construction Permit Dated'..:'_ ... r�.._.I......... ...........................•-------•---------•-•.-------•-•-•-•----•------••---......---•-.....•--_...._ Board of Health DATE............................................................................... FORM 1255 HOBBS & WARREN.. INC.. PUBLISHERS TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS •'� 4' CAST IRON PIPE (OR 12 MAX. 12"MAX. 4"ORANGEBURG(OR EQUIV.) EQUIV.)— MIN. PIPE - MIN. j LEACH � PITCH I/4"PER. PITCH 1/4"PER.FT. PIT PRECAST e e j LEACHING e EL.1p.q. . INVER INVERT e w t u�, •� PIT OR e , SEPTIC-O'°TANK SZ DIST. EL,` i�I. ' >. i EQUIV. INVE��iT EL..S. . . . . . BOX �_= s) . ,e EL.?Yc �.. �, GAL: INVERT._._ iN R�i ©' :;i; 3/q".,;TO I I/2,' ;.� ELS4,Z8 EL %PIo e' �� WASHED w STONE PRO F i�L E OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE �P-38q S I L LOG WITNESSED BY : • DATE ;/7144. 'TIME 67'A Pa BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ENGINEER . ELEV. 5,3s 9. . . ELEV. .. .. . . . . . . Ea efJ�� s�2��luc�:E�cCAtJi9�,,,Q DESIGN DATA : NUMBER OF BEDROOMS lv: -TOTAL ESTIMATED . FLOW 22� . GALLONS/DAY Co�2SG- BOTTOM LEACHING AREA SO.FT. PIT SIDE LEACHING AREA . .�8.f3.Sd SO.FT./ PIT GARBAGE DISPOSAL (50% AREA INCREASE) TOTAL LEACHING AREA 7 14 . SQ.FT PERCOLATION RATESS.7�i/�2J MIN/INCH LEACHING AREA.PER PERCOLATION RATE SQ.FT. //Q.WATER ENCOUNTERED NUMBER OF LEACHING PITS .-" .o&o A(r. . APPROVED BOARD OF HEALTHlTly T��o• TD/C � o,N f�L�, DATE'.`."' AGENT OR INSPECTOR Z07-V8 o Xal EA-Z THO N TKOMA3 E KELLEY CO. 0 N .41121p W. B�IGINEERB—SURVEYORS 24260 S 34i LONG POND DRIVE c'ISYARMO T EQ Y ' PETITIONER 62664 f/v1r o /9B/ Reel / ove 2 d a s THIDMASq�y KELLEY 424260� H AL 17 ; OF o THOMAS ou v THOMAS E.KELLEY CO. ENGINEERS—SURVEYORS 11l 346 LONG POND DRIVE,' x SOUTH YARMOLTM M • Y Z4 7 02664 id LOCATION :SCALE ./.o '. ,r D�ATII=� ' g' PLAN REFERENCE 4A7"-�. ' ; t, i I CERTI T THE �. SHOWN ON PLAN IS LiOCATED HE GROUND c�/P%1J G/.Ti4N;Si�l� A3,SHOWN H ,; DAf E,, PETITIONER: REGISTERED LAND SURVEY �' 1, � � � �' i- � /�� � � t ,,