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0080 PADLOCK LANE - Health
80 Padlock lane Centerville A=193_190 No.42101/3 ORA 10010 (o o o m TOWN OF BARNSTABLE C '.tJ ATION SEWAGE # VILLAGE Cf�"`�T�-J��- ASSESSOR'S MAP & LOT /T3— 190 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ��/� ��J (size) ( X /6) NO. OF BEDROOMS PRIVATE WELL GlIr PUBLIC WATER BUILDER O OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes Noj A r -fo w df/� Fimic .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp iratiou for Bi-nVogal Wnrk.6 Tomitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (01R�..an Individual Sewage Disposal System at ......... Q.....---.�..A�� ,rL.... ---!'c�1 f ---------------- .G .%� 1_. ------------....------........------------ p Local' n-Address 7� or Lot o. ................................................................. ------ ...................................../ ---•---•-------•------------------------------------ Own Address w a�L�o1-s1 --U L 7Uz J =���- (-J,4'i j �1 vas ----------------------------- --- -------------------- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............. ------------------------------ Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ------------------- ----------------------------------......................... �� W Design Flow................. . per person per day. Total daily flow............... 0---------------gallons. WSeptic Tank—Liquid capacity_f_O _.gallons Length---------------- Width................ Diameter---------------- Depth.............. x Disposal Trench—No. .................... Width........ Total Length_........__t....__. Total leaching area....................sq. ft. Seepage Pit No........... ...... Diameter......../0_...... Depth below inlet....4._...._..... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit._._____..-________- Depth to ground water........................ P4 ----•-••••------------------------------••----•-•-----------------•-•••---•---•---••-........................-•---•••--------•------------..........--------- 0 Description of Soil....................................................................................................................................................................... W U ..................•---•----•--••---•-----•---------------•-•••••-------------------•-------------•-•------•-•-------•--•-•-•-•-------•-•-•------•-•--•--•--•--------•------------------------•......-•-- W ---•------- ----- . UNature of Repairs or Alterations—Answer when applicable......./�Q-...__.__�-_...........Z�UC? ___._ ___:��..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance Vbff he board of health. Signed ............ ....... ........ ......... � ........................ Date Application Approved By ................ - ----- .................... ...................... Date l Application Disapproved for the fo owing reasons: ............. . .................... . --.............:..................... . -- ................... . . ... ........... . ................................ . ...................... ............................................................. .. .................................... ........................................ PermitNo- ---------- ---q-----------S......36------------ Issued --------................................................. Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Tontplianre THIS IS TO CERTIFY;_ hat the Individual Sewage Disposal System constructed ( ) or Repaired by ....................................... /Z` U.I at ......................... _,.j '.'............. G ilpl ra " talc r.J........................... - ............. ....... .Ou �.....G�.1...... ......0 -�.�vT ........................................... ............................. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit 1140- ------ --------- dated -------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.. ............. Inspector ................:...�........�.......................................r.......�•'..�.. .DATE..... ........................................................ I ------------------------------------------------------------------------- 415-/P THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �t��tD��Ii IIx�� �II4t���#iLtlt �P�lltt# Permission is hereby granted C...-�1. •U'-'--...---•--•.......'J-----� 5 i......�...: to Construct ( ) or Repair (7�> ) an Individual Se�rage Disposal System at No.....................................................2 .<: j 1S&--4_ Z-11 1 C r-1% /Lv'l L L<- ....--.----- ---------------•---•-------------------------------------•--------------................ Street CC� I q as shown on the application for Disposal Works Construction Permit No._I.y.-_`A�-.:_ �_ Dated___._...!_.. _ .`�' = 1.__.... __ _ � Board of Health DATEyJ ---------•--------------------------- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS C?4•!- -?, No... , _....... Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratioit for Diopoml World. Tonotrttrtion thrrAft Application is hereby made for a Permit to Construct ( ) or Repair P<� an Individual Sewage Disposal System at: ...... �'o ,A --! �oJ -� ���� ------------ Location.Address or Lot No. 14L .----------........--••--• ---- ......----•------ ---------•- --•----- •-•-• ........................................................... Owner Address W �U 2T ��.... �G rU�i-�uv 4-7-i(J)J 7�j t v/�>� ��/ � 1 -N) 1 t l S ----•--- •..................... ...-----•----...........-----•----•--•---........._ .....-----•••-•-•---••-----------•----•--............- _...�........ ------- Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............. ..........._..........Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ------- ---•--- --------------- . W Design Flow....................`�-_.ra-_•_• Z;'___.-----.-__-.gallons per person per day. Total daily flow..........._..... v...............gallons. WSeptic Tank—Liquid capacity ZOQq...gallons Length..-.--__---_-_ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........... ....... Diameter--------- .... Depth below inlet....6............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r7 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................--.. 1:4 ----•----•--------------------------------------------------------------•-------•--------------.------------........... ... ------ ••---------•-••--..---- -O Description of Soil -------------•------------------••-•------•-•-----------•-----------------------.........--•-------------------------------------...........-•--- U --------••-••----------------•---------•--..............•-----•----•--------------...--•-•.....--•...---•---•----------------••-------•--•-----------------------------------------...--•-•---•-----•-•- W UNature of Repairs or Alterations—Answer when applicable.-.----�1)----------4......•......�/JUU ......................)..... .. .....----•-•..'l'` %'a te` -`--5M ------------------------------------- Agreement: The undersigned agrees to install the,aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the Statel Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliances his/been /issued by�he_{bo_ar}d of health. / G� Signed ..........tl�/G �i._�1......©l/ f- %��i1! , / / Dace Application Approved B �.:_... .._.,,�..... �.....,�.......................................................... PP PP Y .....................gy p ,.M,..,.,x, ,.,.. .. t �.J.........�...... (� ...� ....................................................................... . f-..^....Dale Application Disapproved for the following reasons: ................... .. .............. ...................................................................................................................................................................... .............. ........................................ .................................... Permit No. .......... ...�.1..- �,..�-�......-'-� ---...........-- Issued .........................................................D are-.te.... Dare y�-sz :� LO CAT, ION SEWAGE PERMIT NO. VILLAGE cue=��,// I N S T A LLER'S NAME i ADDRESS S U 1 L D E R OR OWNER 1-5i DATE PERMIT ISSUED �z�/�� -� - DATE COMPLIANCE ISSUED L� I .0.V �. .. x THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .------.....Y...0.4W.j ls........OF......�,41.f .a,[., � Appliratinn for Bispvii al Workii Tonstrnrtiun firrmit Application is hereby made for a Permit to Construct ( ) or Repair ( 11"'an Individual Sewage Disposal System at: ,l --------------------------------•------ ---•-----------••---------••------------- Loc do -Address or Lot No. ........, l,tQ?�". n _ ,�JAj� Address A..._..T....s1�/�I....GIK .................................................................................................... Installer Address d Type of Buildings Size Lot............................Sq. feet aDwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons........................---- Showers ( ) — Cafeteria ( ) d Other fixtures .. W Design Flow.............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter..--......--.... Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-.------------------sq. ft. Seepage Pit No----_-------------- Diameter.--..........--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.--................. Depth to ground water..---.--..........-----. 4A Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ • --•• - ---•--- .................. 0 Description of Soil............ •��• --.-¢----- v .-•-----------------------------•---------------•----•-----•---•----- x ••----------------------------------------------------------------------------•------------ ..-------- -----------------------•------------------------------------•--•---------------•-------------- U Nature of Repairs or Alterations—Answer when applicable.......... ---_ -f-® ...... .t .......... --------•------------------•-----••--------------------------------------------------...........---------------................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued the oard of health. Signe . - %� A.......C.. 9r.. Date ApplicationApproved By----•-•-•••......------•---••.•--•-----•-•.....----••.....-•.................•-•--•--•-----•-•-- ........................................ Date Application Disapproved for the following reasons:................................................................................................................ -----•---....-•..............•---•------•-••-•-•••------•-••------••-.....•---•-•-------.....-----••-------------------••-•--•----•------•---•--•••----••••--------••--................................ Date PermitNo................................................... - Issued....................................................... C�z Noff:1 � Fps... s: .. .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ 0.a4Z ......_OF...... ApplirFatiun for Disposal Works Tongtrnrtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( 4<an Individual Sewage Disposal System at 441............................................................................-------------------- Loc do -Address �j�. t✓..: 11 .feL1. Lot No. .........._ -----------------••--•--•----•------- _....._........---- 3 :rs,�r:w, Address •-----•' B._-+---... - 1!�f_. _ ....'__._..... JN_....Lc'�`; %"--.-.•--------------••-------..........................------._..._......__..._................__ Installer Address UType of Buildingf Size Lot............................Sq. feet �-, Dwelling NO. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -----------------------------------•--- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area................... ft. Seepage Pit No--------------------- Diameter.....................Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by........................................................................... Date....................................... Test Pit No. I................minutes per inch Depth of Test Pit------------------- . Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ - ------------------------------------•----------------- Descriptiori'.of Soil a �'� �.......................................................... ---•••-•-•-••-••---•---••_--- ------------ •...... V .-.......--•-•----•=-•••••-••--•-•-••------•••--•••--•-•-•-•-•-•-•=-•-•-•••-••-•-•---•----•••-••--------••••.--•-•-•-•••-•••-••-•-••••-...---•-...---•-•-••••••--------••••...-•--•-•••---•---•--•_•--- W x ........................................-.................................................................................. --- -•--- ......•_-- U Nature of Repairs or Alterations—Answer when applicable_______I� :___ � � _ c Z_!/..._.__.. ----------------=---------•------.--------------_..-----=-------•-----------------------•-------•--•--------•-----------------------------------------------------------•-------------------....----•••- Agreement The undersigned agrees to. install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T ITU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued ,y the board of health. Application Approved BY Date -----------------•-----------•-----------.._.....•••._....-•-••--- --••--•-•••-•-•-•- -•- •-•••••---••-•- Application Disapproved for the following reasons _______________________________________________________ ----------•--------------••---------•Date•-•....__...-- ......-•------------•-----•----•------------•--------------------------------------------------------------••-•----•--••-•------••-•------••-•--•--•-••-------•••--.................................... Date PermitNo.....................................-------------------- Issued....................................................... Date THE COMM NWEALTH OF MASSACHUSETTS BOARD OF HEALTH �rr�ifirtt#r of ft�unt�li�tnr�e THIS Is T ERTIF , That the In idual S c"Disposal System constructed ( ) or Repaired (A--r rti bY-•----- =, - -•-- - -,,; -.-•----._..._••--...-•------------- ----------- ------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s e�ribed in the application for Disposal Works Construction Permit No----• �� "�2------•.••-• dated_-_.-_ __ ____________________ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILY FU sCCTION SATISFACTORY. DATE.... A / ...............:.................................. Inspector-- • --_-••-- THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH f f1�� ....OF...... .. .LA e? a?'? .:...................... .............. r� No...�._.':S�Z.. FEE... - Disposyl urk5 Tun ttr ' n rrutit Permission is hereby granted . . ` = '" = ara'Av__....,. 11 .:............................ to Construct-( Tndividual S"x age Disposal SystFT at No J r Street as shown on the application or Disposal Works Construction Permit No......... r=_ Dated_________________________________________ / .,�' _ Board of Health DATE---- ; - - -- ... ............................................... FORM 1255 A. M. SULKIN, INC., BOSTON LO C`A? ION SEW G E PERMIT NO. 3 2- 3 VILLAGE /93 C IN.STA LLER'S NAME & ADDRESS B UI'LDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i ��� p£ � �� �� c �` ��l Z�` � No.....".. Fx$......2- ..�.�.�.... [!!� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..................... R. -.............................. Appliration for UispngFal Workii Tanstrnr#inn Vamit Application is hereby made for a Permit to Construct (1-< or Repair ( } an Individual Sewage Disposal System at: joe -.. -��,r.ocation- ddress or Lot No TR. �-------•---------. Q:-. rJ -- Q ..-- Owner Address ................................................ --•-• ........................................................ Installer Address •,/ Type of Building Size ... ... ?.Sq. feet V Dwelling—No. of Bedrooms__fl?�...............•.__...._.....Expansion Attic (00) Garbage Grinder (UC) Other—Type T e of Buildin 1 a yp g�9��............. No. of persons___�'......__..___._______ Showers Cafeteria �p) a Other fixtures -------------------------------- -- - -- W Design Flow.................../ZO2................gallons per person er day. Total daily flow....-3%30...........................gallops. WSeptic Tank—Liquid capacity��_gallons Length_ f'.�r." Width_4-`. .. Diameter________________ Depth SL�'�_.. . Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No............../----- Diameter-__`. Depth below inlet...6:...`......... Total leaching area.'. &-0_.s ft. Other Distribution box (� sng tank ( ) Percolation Test Results Performed by..e?Q��-a--- _._.. .__......�..:................... Date......Fater _. ... : .. aTest Pit No. 1..... ......minutes per inch Depth of Test Pit---- .-_....... Depth to ground �J.. _._��!�'G�°" '• 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-____--_-__-----___. 9 ...•................................................................................................-•-•--...............••------••-•---•-•-•-•------•-•.--- 0 Description of Soil.....a1s3. ....._... 0 o __ S ------------------------------------------------------------------------------------ W l ��--------------- --------------------------------------------------'`_A, ----------------------------........................................................ 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 TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig 6d - .------•------- -- -- - -------------------•------------- ----••..... .......•-----.-- DatApplication Approved By-- . -- •---- � - Date Application Disapproved for the following reasons:..................... ................................... -•---------------•••-•----••---------••-..............-••••...-----------•-----------•••-----•--------------•••••----•-----------------------•-•--------•------••-------••--------- -------•--...--•--- y _. Date Permit No.......----•----•---•-•-•. IssuedZ_ ate -• ------ THE COMMONWEALTH OF MASSACHUS,ETTS BOARD HEALTH (9rdifiratr of Tomp iaurr THIS TO CER 14 t the Individual Sewage Disposal System c}acistructed ( or Repaired ( ) by-........ ! --------•-------•---•-------------------••------•---•--- --- ••• .. --- -- or has been installed in accordance with the provisions of 5 of The State Sanitary Code as de cribed in the application for Disposal Works Construction Permit No. ......at '0�7�--'�---..__.._._._.. date�c(__z`_ '_��--------------------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY .....�«°:, 3�yt1".- - n ��?- t y,•'`3x�".'fif'+Cy�°ftr:R�iy i4k�°"A, c+n -.: _... r µInspector ...................................................... A Y ......£ ,.:. .:' '� THE.COMMONWEALTH OF MASSACHUSETTS 'BOARD' O HEALTH Az � / .......... .o ' .... No.............A.......... FEE........................ Perrmssloq,,j reby granted. - ........................................ to Con t or Re ( an In vldual wage Disp al System f� . atNo. •- ------ --z -�.. ... . .... ...... ... . ..e-•----......----- ---------------- Street as shown on the application for Disposal Works Construction Per . No ated....../�"` _'"_ ............. „� +?« �r Board of Health DATE ...`_. i7. •-•---... i FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .• - r Finc f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 04u.. ....................OF..... ......................... Appliratilau for Disposal Works Tonstrurtwit Prrutit Application~is hereby made for a Permit to Construct (. ') or Repair ( ) an Individual Sewage Disposal System at ................................................. Locatio Add r s r Lot No. G 7 .................... . o:_: �'::. 6 .:__"..:......z"......lP�..ro, ...... caner Address - staller Address Type of Building Size Lot.-_45�0210,9, '_Sq. feet U g— �:........•....................Expansion Attic ( Garbage Grinder 4- Other—Type a Dwelling No. of Bedrooms.__.: p•, of Building oi.?A ........... No. of persons......2�................. Showers ( ) Cafeteria a Other fixtures ------------------------------- -- W Design Flow..........................leo..........gallons per person per day. Total daily flow.......... ......................gallons. WSeptic Tank—Liquid'capacityd&5�Ggallons Length................ Width................ Diameter----_........... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No.....__._..l-_._.__.= Diameter...��c. T__:.... Depth below Total leaching area..................sq. ft. Other Distribution box ( Dosin tank ( ) Z Percolation Test Results Performed by. ! .A-G�:..:��7"!'"............................... Date tip/ a minutes per inch Depth of Test Pit-___� •.`__ Depth to ground wate��_:__f `'" '•' Test Pit,No._1......_�.__:. __ _� (s, Test Pit No.,,2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ J ............................................................................................................................................................ Description of Soil Q f .��'� S'�/f. s'�f ` "►� ` / ..........- O/�e°01 Gr�I/3� .Sst�.. ...`.... U W ................................. ------------------------------41 ,7.!" -i 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 MIL LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sitie .. ................ ....................... . ...................... ................................ Datc Application Approved By. - �: = { Date Application Disapproved for the f oll-owing reasons-------------------- .................................................. - } Date Permit No.................................. r-----------------• _� Issued .... Date -\ COMMON\'JEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION (� A( TITLE 5 OFFICIAL INSPECTION.FORM -NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM FORM PART A � CERTIFICATION Property Address:. Cr�Cv3� Owner's Nante: Owner's Address: RECEIVED Date of Inspection: L7 / SEP 15 2001 Name of Inspe to . (please riot) Company Na» . TOWN OF BARNSTABLE �i HEALTH DEPT. Mailing Address. O� __ , -0 VW Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete..as of the time of the inspection.The inspection.was performed based on my training and experience in the proper function and inaintenance of on site sewage disposal systems. I am a DJEP approved system inspector pursuant to Section 15.340.of Title 5(310 CMR 15.000). The system: /Passes Conditionally-Passes rid .Further Evaluation by the Local Approving Authority. ail Iuspector's Signature: Date: The system inspector shall submit a copy of this inspection report to.the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approviirg authority. Notes and,Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will.perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I s Page 2'of.l l OFFICIAL INSPECTION.FORM-N T FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA' T A CERTIFICATION (continued) Property Address: 71 Owner:. & Date of Inspection: ' DI Inspection Summary: Checlr A,B,C D or E/ALWA S complete all of Section'D A. ystem Passes: of found an. information which indicates hat Any-ofthe failure criteria described in110 CMR I haven y 15.303 or in 310 CMR 15.304 exist.Any failure criteria"n tevaluated..are' indicated below. Comments: D. System Conditionally Passes:, One or more system components as described in tl e"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacemen :or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,NO).in the Jor,the following statements. If"not determined"please explain. The.septic tank is metal and over 20 years old*'or he septic tank(wheiher 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 coirtplying.septic tank as alpproved by the Board of:H.ealth. *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. NO explain: Observation of:sewage backup or break out or Fig 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;remov d distribution box isle eled 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 rep aced obstruction.is remove ND explain: F Page 3 of 1'l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATIONr.(coritinued). Property Address: OwnerV Date of Inspection: l C. Further Evaluation is Required by the Board of Health Conditions.exist which.require further evaluation . the Board of Health in order to determine if the system' is failing to protect public health, safety or the environment. I.— Systent-will pass unless Board of Health.deterfnines in accordance with M 310 CR 15.303(1)(b.).that the system is not functioning in a manner wl.ich.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..publichealth,safety and enviroumen.t: _ Tile system has a septic tank.and soil absorption system(SAS)and the SAS is within 100 feet of a surface eater 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 DCP 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 ppnn,provided that no other failure criteria are triggered. A-copy.of the analysis must be attached.to this form. 3. Other: 3. Page 4 of 1 I ,. , , OFrICIAL.INSPI✓CTION FORM—NOT TOR VOLUNTARY ASSIuSSMI✓NTS Si BsuRFACE SE WAGE*DISPOSAL SYSTEM INSPECTION FORM PART A 'CERTIFhCATION(continued) Property Address: Owner: k/?AIA-zr�"IL Date of Inspection: 01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to''each of the.following for all inspections: Yes No ,. _ . . . 1Backup 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 v1clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or Xcesspool a✓// Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2-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. VAnyportion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface wate,t supply. Any portion of a:cesspool or privy�is Within a Zone l 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 he attached to this formal (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 systemfails.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:fihe system must serve a facility with a-d esigh:flow of 10 000 gpd to:15,000 gpd. You must"indicate either"yes"or"no"to each of the following: (The following criteria apply to large.systems in addition to the criteria above) yes no the system-i.s.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 1I 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 tile Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM—NOT FORVOLUNTARY ASSESSMENTS SUBSURTACE SEWAGE DISPOSAL S.YST LM INSPECTION FORIYI 'PART B CIiECKLIST Property Address: 4 Owner• � ���. • Date of Inspection: Check if the following have been done.You must indicate"yes"or(trio. as to each of the following: Yes o Pumping.information.was provided'by the owner,occupant;.or..Board of I'lealth. ✓Were.any of the system components pumped out in the previous two weeks? _tZIN Has th.e system received normal flows in the previous two week period T lave large.voluntes.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 foi•signs of sewage backup _v/— Was the site inspected for signs of break out? V" _ 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 scuts 7 Was.the facility owner(and occupants if.different from owiier).provided with.information on the proper maintenance of subsurface sewage disposal systems 7 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 1 OI+'r1CTAL INSPECTION-FORM_NOT FOR VOLUNTARY:ASSrSSNirNTS SUBSURFA.CP S MAGF-nTSPOSAL SYSTEM INSP CTTON,TORN PART C - SYSTr1VI M ORMATION Property Address: �UIALC Owner: Date of Inspection: 0 I FLOXV CONDITIONS RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual);.. DESIGN flow based on'3l0 CvIR 13.203� example: 11:0'gpd x P of'bedrooms): 331 Number of ctirrent residents:a,C /�J03 Does'residence.'laave.a.garbage grinder(yes or no)i . Is laundry on a separate sewage'system (yes or rro) Hf yes separate inspection required] Laundry system inspected(yes it no Seasonal use: (yes or no.): . Water meter readings, if .vat ilah'le(last 2 years usage(gpd)): Sump pump(yes or no : /fir /t � ,�➢ i'C! Last date of occupancywj COMMDRC-INUINDUSTRIA.L1/19V Type of establisliit nt:.. 'Design flow{based on 310 CMR.15.203): : : gpd Basis of design.flow(§eats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tatik 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/ase: OTHER(describe): GVNEIIAL INFOTWATION Pumping Records Source of information:. / Was system.primped as part of the in petition(yes or If yes, volume pumped: gallons--How was'civantity pti.mped determined? Reason•for pumping: 7,- SYSTh,M ptic tank, distribution box,soil absorption system Single cesspool Overflow cesspool _:Privy _Shared system.(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be -obtained from system owner'.) —Tight tank ,Attach a copy:of the DEP.approval Oher'(describe): A roximate age of all components da.e install d (if known)and sourc of infer at'on; Were sewage odorsdetected when arriving at the site(yes or no Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: p MA Owner:�A; � 1 d Date of Inspection: 1 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: Continents(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:.-4Zconcrete_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: i ' X Sludge depth: J 11 Distance from top of sludge to bottom of outlet tee or baffle: Scuin thickness: P -0 1 Distance from top of scum to top of outlet tee or baffle: Distance,from bottom of scum to bottom of outlet tee or baffle' How were dimensions determined: V)4410'1Aa1 "h"': Comments(on pumping recommend tions, i let and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert, evide ice of leakage,etc.): E� A fi /r X' V' � .. GREASE TRA! Tecate onsite 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: Continents(on pumping recommendations, uilet 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 LNSPECTION CORM—NOT FOR VOLUNTARY!ASSESSMENTS SUBSURVACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR 4 PART C ' SYSTEM'IN]r,OkkATION(continued) Property Address: Iwo � Owner:�A959 Date of Inspection: TIGHT or HOLDING TAN]C: (tank mustbe pumped at time of inspection)(locate on site:plan) Depth below grade: Material of construction: concrete_ metal - fiberglass,.__ polyetiiylene 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: t,✓ .(ifpresent 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 lea age into or out of box, etc.): .r PUMP CHANIB r(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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: _ Owner: Date of Inspection: , /f� p/ SOIL ABSORPTION SYSTEM (SAS):. (locate on site plan,excavation not required) r. If SAS not'located explain why: Taped Ion leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: imiovative/alternative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil; condition of vegetation, rr rr CESSPOOLS:_,I&X-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 pondilig,'conditio,n of vegetation, PRIVY:At oocate on site plan). Materials of construction: Dimensions: Depth of solids: Comments(note condition.of soil,sighs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION TORM OT I+OR VO`LUNTARY,ASSLSSMENTS SUBSURFACr SEWAGE DISF SAL SYSTtM INSPECTION FORM NART C .SYSTE MINFOII2MATION(continued) I Property Address:Sb Owner: A Date of.Inspection: SKETCfI OF,SEWAGE DISPOSAL SYSTEM Provide.a sketch of the sewage disposal system include g ties to at-least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate ww(lere public water sdpply.enters the building. I i C�v 1 L� ,\ q1 , O 91') ' 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to.ground water 2-2� 'feet Please indicate(check)all methods used to d.etennine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database;-explain: You trust describe how you esta.blislied the high.ground water elevation: .-- 11 r !e- p� 3 /�� cis ed Permit Number: Date: Completed b HIGH GROUND-WATER LEVEL COMPUTATION 4P. Site Location: �/�f,�-' Lot No. s � x Owner: Address: V Contractor: [30tjj � Address:' Ji � Notes: STEP, 1 Measure depth to water table 91le9 z _..... to nearest 1/10 ft. ...................:.....:.................................................... .Date _ month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well....................... ........... Water-level range zone ........................:..:......................... 1 STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well ............:.............. / 7 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone(STEP 213) zD determine water-level adjustment .....................................:.................................................... STEP 5 Estimate depth to high wager by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ............... 247 Figure 13.--Reproducible computation form. 15 07-20-2000 03:14PM CEHT CST FIREDEPT 5weg- "2385 P.02 make appncaaon to focal Fire Department i Fire Department retains original application and issues dupscate as permit. _ _ au �? aIZJc�YYaHTLCG• Cam'%"G��+n�ixvice4 — -'�,ycz,., .• [Ye* 1'G'1/E'/Yl�+:•n Jf APPLI ATI d PERMIT [Fee- an - for storage `.ank remcv_] and transportation to approved tank disposal yard in acccrdanee with the provisions of M.G.L. Chapter 146, Section 38A, 527 CMR.9.00, application is hereby rrta��e by: 1 ankOwner Name' i� rint Herbert Ruhr Addrass_, 00 Padlock Lane, Centerville, MA 02632 _ - 91l8e1 —C+ry sure Zb it Company Nance Co.or Individual ronracl P.O. Box 472, S. Mnis Addrr3Ss - _ Addres -- —__ Fbmt PAW Signature(if applymn..'tr_ Signature(if apply nu-,cr-ermit) _ IFCI Garune: other f IFC:i Cenif ed = _S? _ -_ other �— Tank Loca+ion 80 Padlock Lanz, Centerville, MA -- :,fedt RCgreSs Tank C;apq&y(gailcrr< 1,400 — Substance last Stcri` �l2 Fuel. Cliff — I( s ' T .-'✓ e ank Dimensions;dsa".�--• x f.,nyth}-- —v---- -----— -_---- � . l r ' f III l Remar'Ks_ Firm transposing waste Advanced Environmental State Lic.*_ 11AA5083856100 I Hazardous waste E.P.A. Approved'ark dispcszjy*urd James Grar.t _ �,,,_,_•,_Tankyard# . 03501� i i ;ype of inert gas v_ent n,—.._.____Tank vard address —, Readville, MA -- — i Centerville 019'20 � City or Town -----FDlC# ._P©rmit# Gate of issue _,July 20 2000 Date of expiration Auguvt _3,, 2000 20002902953 -- i Dig sate a0proval nurrtr �Diy Safe Tcit=:w Tel. Number 800 322 484a t Si, gnats rs!i Title of Of -er granting permit t v - After removal(s)send Fr c -; �-2 d try Lccal Fire Dept.to UST Reg:;iatory Compl;ares Unit,One Ashburton Place, Room 1310, 60ston,NA. .';8 '.6t8. i TCTAL F'.D? — U7-2'C-2000 0:=: 4Pf'; CENT CST FIFEDEPT ScBY�12:_85 P.02 Make application to focal Fire Department V dire Department retains original application and issues dupFwate as Permit. 1 � _ - �niryz.�nc7u.�=�cr�Cd a�G����e�:�cu,•�zeei � j-/�� � �� I rgo,rtrei eG — .facz r� C '�-x.► ✓�reyuvr�r +rn j APRLIATI and PERMIT IFee:_�s.oa - I for storage `.ank remcv l and transportation to approved tank disposal yard it =cccrdance with the previsions of M.G.L. Chapter 146. 'Section 3FA, 527 CMR 9.00, application is hereby rnaj•e by: F.-an Name(pie��a print} — Kerber: Ruhr X >7+atv�e adrrrns r,pennwl Addrass� 60 Padlock Lane, Centerville, M:, 02632 - 1 �rroer CN Stare bo i Cornpany Name_ _ �,va nr�ri �;rnrmlar,ra t Co.or Individual P.O. Box 472, S. fenwis Address _ Addre� AVY Signature(it applying-cr 4 Signature (it appiyinc -.r rennit) I -- IFC:Germe= Omer ar Tank Location_ 80 Padlock Lane, Centerville, MA -- , Ntedr paorsss Tank'Capgci'y(gallcns —1,004 $r,bstarce Last Stcr #2 Feel Oil. Wank Di{ne'nsions;dia: x length)— I I � , Lr f ( � 1 I Firm transporting wage Advanced Environtrenta? State Lic. #_ ilIA5083856100 i Hazardous waste rnerr-= E.P.A.# i Approved ;zrk disocs '!�-d James Grant —Tank yaN# 0350i } ype or inert gas verEiag--_Tank yard address —. Readville, MA _—_- — Centerville 01920 i City or Town. _._ �_.._._ _— -----rD!D# _Permit# I{ 4 Date of issue :Italy 20, 2000 Date of expiration August_ 3 r 2000 20002902953 Dig We apt rovai nurrky--r Dig Safe Tcit=:�Tel. _Number•800-322.4844 Sil "gnaRLrs I Tit4a or Of zc r-ranting permit - Alter rernovai(s)send Fcr- 7-P-290R signed ty Lccal Fire Dept.to UST Regulatory Compiiarcr Unit,Cne Ashburton Nac*t, Room 1310.8cston, 'MA. �2::8-,618. ap..')ao r e, mow a oc, TCTAL P.D2 I -, I . . ,.�.M.•.'.,,..-.. •- -- ors ,.,.h..... ..,.. ,......,.,...._...,.,..,,.,..»,...., .,,.. •� ,A-�,p��;�-1'-R'�.��4 X:"A l,!.r',i,4V t e5,"".'.,r_��4.,r_,t..,4.l . fI.,,�..I--1,�-.,,,�---S7f,*-',I I-. II may,-.,r _...-...G..w-wr..>•.w,.k,.'+P..' 're'/^-.tom �'7''Y3=�¢-- R-•..-. , .. •+,"• . ....__ ....a '.>s-3° ,t,, Y ,may�-.ti,a:>,; _ ...,,. +V- ,� _''. l• _L`. �� z-,. .I II�I.�,.-',I- II I�,,I"'�� -,,�,,-. . 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