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HomeMy WebLinkAbout0025 PATRIOT WAY - Health 25 Patriots Way Centerville A= 192 214 UPC 12534 No.2153 OR_ — �• Commonwealth of Massachusetts C6�y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 25 Patriots Way l�l Property Address Anthony Tripodi Owner Owner's Name information is required for Centerville MA 02632 06/16/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out ` forms on the computer,use 1. Inspector: only the tab key to move your Brad J. White cursor-do not use the return Name of Inspector key. Bluewater Company Name 350 Main Street Company Address West Yarmouth MA 1,02673 City/Town State Zip Code..; c-� (508)775-2800U _ t Telephone Number License Number G f- N � B. Certification ; I certify that I have personally inspected the sewage disposal system at this address d that Me r information reported below is true, accurate and complete as of the time of the inspec 'on. The-inspeltlon was performed based on my-training and experience in the proper function and mainte ance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Sec ion 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority o ` 06/16/2008 Inspector's S' ture Date r 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. t5insp.doc•0310$ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is Centerville required for MA 02632 06/16/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 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: System fully meets pass criteria. Home has not been occupied since May 2006. Leaching pit was bone dry at the time of inspection. B) System.Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is required for Centerville MA 02632 06/16/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp.doc•03/08 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is Centerville required for MA 02632 06/16/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 co of the analysis must be attached to this form. 99 copy 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E?�" 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. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts w . Title 5 e Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is Centerville required for MA 02632 06/16/2008 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No El Lid'/ 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. ❑ D Any portion of a cesspool or privyis less than 100 feet eet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates'absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either yes or"no"to each of the following, in addition to the questions in.Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA).or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section.E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304.The system owner should contact the appropriate regional office of the Department. t5insp.doc•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 15 I Commonwealth of,Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form--Not for Voluntary Assessments M 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is required for Centerville MA 02632 06/16/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No E / ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Rk"" Were any of the system components pumped out in the previous two weeks? ❑ Ind Has the system received normal flows in the previous two week period? ❑ Lid' 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) L� ❑ Was the facility or dwelling inspected for signs of sewage back up? L/ ❑ Was the site inspected for signs of break out? 5 ❑ 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? Lg' ❑ 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: 5 ❑ Existing information. For example, a plan at the Board of Health. Ltd ❑ 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)] t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 25 Patriots Way Property Address Anthony Tipodi Owner Owners Name information is Centerville required for MA 02632 06/16/2008 every page. CityRbwn State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Unknown Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown Number of current residents: 0 Does residence have a garbage grinder? ® Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ® Yes ® No Laundry system inspected? ® Yes ® No Seasonal use? � Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 0 Usage Sump pump? ® Yes 9 No Last date of occupancy: May 2006 Date CommercialAndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day Y(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: Last date of occupancy/use: Date Other(describe): t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 II Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is required for Centerville MA 02632 06/16/2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Unknown 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 ❑ (NO 1 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): Approximate age of all components, date installed(if known)and source of information: System was installed approx 1980 Were sewage odors detected when arriving at the site? ® Yes fillill No t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is Centerville required for MA 02632 06/16/2008 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site.plan): 1611 Depth below.grade: feet Material of construction: ❑ cast iron J0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): 30, Building sewer is in good condition. No evidence of leakage, Used camera to check piping Septic Tank(locate on site plan): Depth below grade: 110, 811 feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ® Yes ® No ------------------------------- Dimensions: 8'x 5'x 4'-10" Sludge depth: lit Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness Oil Distance from top of scum to top of outlet tee or baffle 9rr Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Measured t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage-Disposal System Form-Not for Voluntary Assessments - 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is Centerville required for MA 02632 06/16/2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (coat.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet baffles are in good condition. No evidence of leakage in or out of tank. Tank appears to be structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is Centerville required for MA 02632 06/16/2008 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ® Yes ® No Alarm level: Alarm in working order: ® Yes ® No t 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 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.): Distribution box is level. No evidence of solids carryover. No evidence of leakage in or out of box. Distribution box was replaced in May 2006 and has a riser 14" below grade. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ® No Alarms in working order: ® Yes ® No t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 I I commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is Centerville required for MA 02632 06/16/2008 j every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: --� 1 C 6' x 6' ❑ 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.): Soil is dry. No signs of hydraulic failure. Vegetation is normal. No ponding. Leaching pit is 28" below grade. Pit was dry at time of inspection. Stain line indicates liquid at 4'at some point. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Patriots Way Property Address Anthony thon Tri podl Owner Owner's Name information is Centerville required for MA 02632 06/16/2008 every page. Cityrrown State Zip Code Date of Inspection i D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ® Yes No 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.): t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Patriots Way Property Address Anthony Tripodi Owner Owners Name information is required for Centerville MA 02632 06/16/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. 3 A 8 2—tD y c o i D Al - 21 a Al 27 ° $14 v v {- , C LI :. le W t5insp.doc•03/ I Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 25 Patriots Way Property Address Anthony Tripodi Owner Owner's Name information is Centerville MA 02632 06/16/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: -ow 11'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) [ Accessed USGS database-explain: Well SDW 252/Zone B/Level 46.8'/Adjustment 1.4 x 12"= 16.8" You must describe how you established the high ground water elevation: Augeered through the bottom of the bone dry leaching pit to a depth of 11'with no indication of groundwater. Bottom of the leaching pit is at 8'-4", If you add the required adjustment of 16.8"this bring the total to 116.80".Augeered to a depth of 11'.This leaves an additional 5.2" of seperation. Well SDW 252 Indicates water level @ 46.8'. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 .......... ............ ........... ............ ------ IP, --- ------- ------------- _jI.-I.-J-1- ----------- V. 17 J. Le ------------- FIN IiL Le .. ......... 90-VPI ,mil Zoe to I Fq ...........- air ---- --------- ........... - ---------- 26 M9 -A' AA' ---------- I i------- i s _ Regulatory Services « iaxNsrea[.s. Thomas F. Geiler, Director MASS. v � �arE1639- ` Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:ISEPTICOisciaimer Private Septic Inspections.DOC Ol 1 Demo YJ`J teelace 7: .h..•.:'Mrmlq!4Rv�Fevv.'Ae�,�^°"^^""^,r°oY"?MM4,g4p,�'nYm'aeewMr- '., "a.wn:,•mwx mM<+wuMa'^m'rv,�r,va^"�p.�+MauYAr�avurvarm f 7� " " N� TOWN OF BARNSTABLE 1 LOCATIONQ ®A�� d/ Lt>7� SEWAGE# a L� VILLAGE C 5� tV 7T ASSESSOR'S MAP&LOT j/vSP a c ro✓2 � � / lei&TA�LiR'S NAME&PHONE NO. P L `1.4 A-,)(*G,-7-; SEPTIC TANK CAPACITY f 64� /4�C !/ N LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: C 6N+PL E DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by P ,4 • IMP S C 07 e 4S/ _ TOWN OF BARNSTABLE LOCATION -s /I'l 0 f ''✓/I SEWAGE# "0 VILLAGE C �T ASSESSOR'S MAP&LOT I / INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /e £PL,4 C £ �D LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER 1 /e G])C PERMIT DATE: S'S'O 6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by o a� �14R 3ki- 1w c 0 LOCATION � SEWA PERMIT NO. VILLAGE C6V dzit�r- IN.STA LLER'S NAME a DDRE S B U I-L D E R OR OWN ER 67EG) J: c�A GATE PERMIT ISSUED "- ,� DAT E COMPLIANCE ISSUED , �, �� l V � L »'� A/ q� (/ li �� T No. .C=Ibo G �� Fee LJ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rphraction for �Digonl �§pgtem Cougtructiou V--ermtt Application for a Permit to Construct( ) Repair(- grade( ) Abandon( ) ❑ Complete System t�`IIndividual Components Location Address or Lot No.A� P,4 T� /!.>t/5 "",3" Owner's Name,Address,and Tel.No. Assessor's Map/parcel a- 1 ,S f�A Tii ITT wIa (� /ti7' Installer's Name,Address,and Tel.No. d .9; 028a Designer's Name,Address and Tel.No. /v c 3-0 AIMV;i Type of Building: Dwelling No.of Bedrooms �1 y 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) £ /r £ • J 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 Board of Health. Sig ed ' — Date _S Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. �� —�� Date Issued J�-- 1No. r-�L� Fee V THE COMMONWEALTROF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Bioo al �&p!tem Cougtructiou Permit Application for a Permit to Construct( ) Repair(A)0 Upgrade( ) Abandon( ) ❑ Complete System FP dividual Components Location Address or Lot No.,;L RA r/P /G I S Gv,d y Owner's Name,Address,and Tel.No. (2 £yT 7_X0/ /0477) / Assessor's Map/Parcel ,,ot-\.. 5..,P L', O oQ S A TIP/4T S 4,w d y I? Z/V 1-- Installer's Name,Address,and Tel.No. " � $ p pG Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms //0 VS 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 �[ F f O Nature of Repairs or Alterations(Answer when applicable) jo c � ,® �• �-~"" Date last inspected: Agreement: ti 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 Board of Health. ,: Sig ed S9- �°64, Date .S a'/6 Application Approved by Date Application Disapproved by: Date for the following reasons r Permit No. ��� Date Issued $ ; -------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY1,that the On-site Sewage Disposal System Constructed ( ) Repaired ( (,a- t-Upgraded ( ) Abandoned( )by �0I4& r O � o Iy/4,1/1< S T C.le - T, A at A �' R: 1675 44., 4 y- C E Aj has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer �. �� rr 13�f� Designer #bedroom Approved,designaflow gpd The issuance of this permit sWaall not :e construed as a guarantee that the system will func ioe as designed. Date / Inspector -------------------------------------------- No. CSC) o — . 9 Fee o 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 'Wi5poot �&p5tem Con,5truction Permit Permission is hereby granted to Construct ( ) Repair ( 4o 'Upgrade ( ) Abandon ( ) System located at a J- '00 29 Z4 /,0 Z3: 6t.0 4 15!' (2 f 4-7— and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this p vt. Date (D< Approved'liy �, i COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS c DEPARTMENT OF ENVIRONMENTAL PROTECTION �q SJev 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Map 192—pare 214 s Property Address: 25 PATRIOTS WAY =; CENTERVILLE,MA 02632 Owner's Name: TRIPODI,TONY ^.a Owner's Address: 20 PERNA LANE 7-1 S' RIVERSIDE,CT 06878 Date of Inspection May 4,2006 - C Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco u7 r), Mailing Address: 350 Main Street. West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ",ta— Date: 5-4-06 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 tot he buyer;if applicable,and the approving authority. Notes and Comments " *"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY 4,2006 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 CUR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y, N, ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(,whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if 14ith approval of Board of Health): broken pipe(,$)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(,with approval of the Board of Health)" broken pipe(,$)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI, TONY Date of Inspection: MAY 4,2006 C. Further Evaluation is Required by the Board of Health:N/A _ 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 riv is within 50 feet of a surface water P P Y i Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(,SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY 4,2006 D. System Failure Criteria applicable to all systems: N/A 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 pit is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (,Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CNIR 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: N/A To be considered a large system the system must service a facility with a design 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 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' r y m a nitrogen sensitive area ,Interim Wellhead Protection Area g 1WPA)or a i 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 is 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 CUR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/1.5/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY 4,2006 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?Qf 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,including 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)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 CNM 15.3020yb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of l l . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY 4,2006 FLOW CONDITIONS RESIDENTIAL✓ Number of Bedrooms(,design): 4 Number of bedrooms factual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 440 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(,yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): YES Water meter readings,if available(Jast 2 years usage(,gpd)): Sump pump ayes or no) NO Last date of occupancy: UNKNOWN COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(,seats/persons/sqft,etc.): Grease trap present(,yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(,describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system ayes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract Ito be obtained from system owner) Tight tank Attach copy of the DEP approval Other(,describe): Approximate age of all components,date installed(if known)and source of information: AROUND 1980 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(,continued) Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY 4,2006 BUILDING SEWER[locate on site plan): ✓ Depth below grade: 6" Materials of construction: Cast iron ✓ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments ion condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK Qocate onsite plan): ✓ Depth below grade: 8" 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: 1000-GAL PRE CAST Sludge depth: 6" Distance from top of sludge to the bottom of outlet tee or baffle: 24" Scum thickness: V Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT&TAPE Comments(,on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL,TANK&COVERS AT 8"INLET TEE—OUTLET BAFFLE. NO SIGN OF LEAKAGE OR OVER LOADING. GREASE TRAP(Jo Gated on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (,explain): Dimensions: Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(,on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY 4,2006 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(Jocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: .P 61'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"X 16"—22"BELOW GRADE WITH COVER AT F ONE LINE IN—ONE LINE OUT. BOX IS NEW—5/06. PUMP CHAMBER: N/A (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.): Title 5 Inspection Forni 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(,continued) Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY 4,2006 SOIL ABSORPTION SYSTEM(SAS): ✓ Qocate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(,note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE(,1)1000-GALLON PRE CAST PIT. PIT&COVER AT 28"BELOW GRADE,PIT DRY STAIN LINE AT 4",LEACHING WORKING. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionylocate 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 ayes or no): Comments(,note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A 4ocate 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.) Title 5 Inspection Form 6/15/2000 9 i • Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY=4,2006 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. i � 9 Title 5 Inspection Fonn 6/15/2000 10 Page 11 of 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PATRIOTS WAY CENTERVILLE,MA 02632 Owner: TRIPODI,TONY Date of Inspection: MAY 4,2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 4W 7" feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: USGS WELL DATA. WELL SDW 252 AT 4071. r /oi7— i Title 5 Inspection Form 6/15/2000 11 07f ��:��.�. � C� � .��q ������. Coy►. ��• No.................1/... Fimim ....... ' THE COMMONWEALTH OF MASSACHUSETTS 4: BOARD O HEA Me (, f1'iYf OF......... _ ........................... Appliration for Disposal Works Toustrnrtiun ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syst !-y 1CdL .................... *E ..........................o.oc ddress Lot N O .............__. n Address W ............... �?...z�.?�.......................... ................................ L©.-_...... Installer Address Type of Building Size Lot_ ---5?' 1 Sq.We, t Dwelling—No. of Bedrooms.............�-�0.................Expansion Attic � Garbage Grinder Other—Type of Building .................. ........ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ..---•--------. ••-------•--... • - W Design Flow.................�� .................gallons per person per day. Total daily flow............... ...........gallons. WSeptic Tank—Liquid capacit/.gallons L th................ Width................ Diameter................ Depth................ Disposal Trench—No. ................... Width.....I.&1_.... Total Length. ,,..._....• Total leaching area___.__.... _......sq. ft. x jj Seepage Pit No.......... ..... Diameter----1.Lf_:::Z Depth below inlet..... Total leaching area��l�._._sq. ft. z Other Distribution box ( Dosing to ) Percolation Test Results Performed by..... Z�f!_ ._ .................. Date..... .:9. .. Test Pit No. 1_.,'..:: p p p ground minutes per inch Depth of T sn t Pit ...!-__-�. Depth to water.._./ll?i'C�s- Gi, Test Pit No. 2................minutes per inch Depth of Test Pit................ ° Depth to ground water........................ O " `�� .. .......��-- . �.i�►l ------------........................................................ Descriptionof Soil------------- . .............. �----•-. ...--- ---------•-------------.....--•-•-----....-•--•-------------•--•--...-•---- x .....-----•-----•-••••--••--------------------.. .... ----------- ..�----- ------•----- c., 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 iII= 5 of the State Sanitary Code— he undersigned fur :er agrees not to place the system in operation until a Certificate of Compliance has bee i s by the bo- d of he th. S' d. �� ,/tom---••-----•-.. ��- y _ D to Application Approved By..... . . ---..... . ....._.... u� ^2a 9:.......... Date Application Disapproved for the following reasons:----------------------------------------------------•--•-----------------------•------------------...--•-------- ..............•-----••------••---•..................---------...........--•---•-----------••-•----------•--•........----•----•--•-----...--••----•----• •••-------•---•-----------------•-•--•--.....•. /�,`� � 7 .. Date Permit No. .... Issued f4 ...................... -•---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 0)4r H E A T �C 2......... l: ... ..-'------............................. Appliration for Di-span al Works Tomitrnrtiun 1hrntit Application is hereby made for a Permit to Construct ; J or Repair ( ) an Individual Sewage Disposal System . ........,.M_.dressLoca , yf, ....... .... r�t--•............... ......' No. ...----- f ..............0 ...... ... ---.............. ...... O}�ner f Address t /...-� 1J. /ir......------•-•-------- ................................ �, _2..----�'�....t:�_V.. ...... a � Installer Address CC�� Type of Building Size Lot., fZ_1..Sq. feet �-, Dwelling—No. of Bedrooms......... / __..............Expansion Attic O<J-' Garbage Grinder ) Pk Other—Type of Building ............................. No. of ersons........................__.. Showers a' � - -•----------------..................................................................................... ( ) — Cafeteria dOther fi to ---•••---------•--•----••---••-------------------------- - - ------ W Design Flow............................................gallons per person per day. Total daily flow............... .�A...............gallons. WSeptic Tank—Liquid capacity,&o.gallons Le g I h................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width...... Total Length....,,... Total leaching area....... ._. ...sq. ft. Seepage Pit No----------/------ Diameter.....�L(_..-.Q Depth below inlet.....4�...n4O Total leaching area_;;;W&...sq. ft. Z Other Distribution box ( Dosing t�a� ( ) Percolation Test Results Performed b __..... ../. :_.. ....,�.;��..-- Date.................... ................. Test Pit No. 1...�.-.Qminutes per inch Depth of Test Pit. .. Depth to ground water..... 7U 44 Test Pit NO. 2................minutes per inch Depth of Test Pit ___..........._._. Depth to ground water........................ o ...cn- ?.---------••• ��5..Q_�----- 0 Description of Soil-•----•-•---..2_ ... :5----_------.-- .� ! .�1--------------------••---........-•--••-•--•--••----••-•---------•-------- ---••-•-••------- V W — •-------•---------------------------------- ------•--------- x y --- /-� n e S ------. 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 TIT .% 5 of the State Sanitary Code— he undersigned furt ier agrees not to place the system in operation until a Certificate of Compliance has been;i u by the bD0'jVd Of h th. J .rr1. .. ........ r. Date Application Approved By..-/ ............. ••--••••...�. .........-•- I................................. = `- , -------- Date Application Disapproved for the following reasons----------------•----•--•---•------••----------------------------------------------............................. .......•------•--•--•----....•-------•-•-•---•-•..............................•-----••-•-•--------...•----•-...-••-••-•--•-••--•----•--•-•------•••---•----•---•--••--•--------••----------------------- Date PermitNo............................-............................... Issued_...............................:....................... Date ;. � �i Y ,t a Y'ltt.#t„r' r>�; r I r qri 5 , J J r 44 I *9 (1, 1 U 11 9 / , '7� y �,k,9 a q ,}r� I +i Ji i r a )' � •.,r � pr��, 6 K �1 h-• " � A y t �t i -,�� + S i 'r' rrt i Ir c- r��� � t�s�Y, '', � + G f'C } � , �'It•ISn• I : r e � 'S�r�i �r }t.+t 1 �.+y. i'Z h Q 4`.e a '�t'� � � 1. `i 1.�• ..1'+v � - � it J� �o�+t k 4,5% �tA x� 1 �4 ) 7 r#YI°; ! •, 1 1 ., e +x '' �� ��� I� a',' tt ':3� 5 .`.1 �', ''+ P T _►2' f #: t �/� \/ ti#fr yfk�tr ^1; ?' LEGEND ;��kti == a, !A' v I' F_yISTING S POT__.E L E VAT 10 N, CERTIFIED PLOT PLAN t ' l S T I N G r CONTOUR -r NiSHED SPOT . ELEVATION r^s Ttnr_l.D T n 'J UN �k PPP<OVED •BOARD" OF HEALTH - �` � ��A ®�.� o �� AA .�•� v ' xDriTE AGENT L. SCAE DAT•E.: �aH �G I9� — — — ---- -- — — — r RED 6E ENGINEERING CO. ING ! �,. { . CLIEN I CERTIFY•` THAT THE PROPOSED:, q +vi REGISTEREs71 "REGISTERED)i 7fr�Gy BUILDING SHOWN ON THIZ$ PLAN � t i JOB NO. . ,. h CIVIL LAND p� CONFORMS TO THE ZONING LAWS { DR. BY ENGINEERS' I.. SURVEYORS — OF BARNSTABL E MA S. i.•• F' 4 MA , � 7' fvAIN T CH. BY 7'.. F Js+ ;•!MOl Ii, M;�,3 I�iYF1NNl';,"Ma'. .' SHEE 0 DATE E LAND SURV£tYQR �i" NOTE. ' /yc-.-E�'Tis✓E�4 ?`f•I S:EPT/G:.T.gN' OR '. �E R f#CH/N P/ �4 �Dl�e� Tfd.9.N /2 �ELOIN 5WA 24®/®E� A. A/�L� e�.C'R'.�T� COKE - -SNALL �� 0,W0'[Id,.VT 7'0 -' 'AD4 2'A �d 97 ® 4~PVC P/PE CONCRETE "E.4VY CAST //PO/Y Cb�/ER�Sf�.4L� !3E USE.0 h91N. P/TCIWco AveR5 /FIN 1CPRI VZ=PVA Y r� o MiN. CO/VC�• T-E . c_ dRAOE CU VE'R — CLEAN .SANO •• _ _ . . 7 _ BACIC�ILL 4"C ST b - r Qe� _ 2-"LAYER IRON P/PEGi4L. 0.. v.o o P o:Q of 44 M/At.P/TCN — D/ST s 4 ® ® ® -® o o e .e n °a W,45HFD 5701VE %4 tl PEm �" SEPTIC TAA/,K m n o m • o 0 0 0 0 ® e '® ,o a s _ BOX o ® 0 s • . ® o • o; ®v o OEFFECT/.VE 0 v o o a OgPTN ® • o c e o WASNED STONE e 0 0 ® 0 •'0 8'0-• o t e m e ® • • ® m e e � a tr pj �' PREC,.gS T SEEPAG E.f l M6��RT Ed Bd1A7/ONs f S_____�v ® o e e r •- o -® o m ate ' e IN!/EAT AT AFT= �------._—_—_� INLET SEPT/G' T.4N/C FT, �_ FT. O/AIy7. j C SEE T�9ULAT10N�= OUTLET SEPTIC TANKS FT. INLET DISTR/A5lsT/ON BOX��T. 5 G�POuNa ,1 .�tTE� TABLE ? SECT/ON OF i ! ;,, t c � - OUTLETD/sTR/BUT/UIV BOX 9�, 9 FT /NLsG7 LEACH1)Va /SIT . ��t3�FT .SEAVAGE ,®/e5°/�®b5's� L .SYSTEM 'TABI:�L.�TI®/eI - LEACHI V& SCALE %4-" /•_ 4N 131MENS/O'A/ FT. DE.S/GN cxl r.=,vlA = D/HENS/ON A FT• AWAYSER OF®E®ROOMS G,a ee,aoEo/SPos��u�/r SD/L -.LOG TOTAL EST/MATED F*J_oAo/�a"'G.4L.1AoAY SOIL TEST A/ NUMBER QF LEtACH/N!o P/TS__ ELEY, oAT,5 OF SO/L 7'_PST S/OE LE'ACH/NG PER PITSQ f T - �Q/ l / RE.�C/L3'S D�IlTNESSED L3Y e h I r1 S OOTTOIK LEACH/MG PEOz PIT so. F'T. . A&W CCAAT'/0" DATE I ®'S Ml Al'I/NCH TOTAL LE5ICH//VG AREA 1-4- c SQ. FT. a PZkCOLA7/®N RA7Zj4L.AA � .>�ESERtiE LEACHING AREA S4. FT. '. ROBERT IS No.22162 �•'V ��►� $'1 a� V r" 712 AfA/•N b r .:, Y MAGROUN® Wi4TGsi� �/1YC'DCliW7"�12E0 x OlYANN/S -Algg5 =s ga -*Y,gRMOUTH,NABS.• 3 w '�.wa:=.'bb..'.e5'`r-♦ _ .- _ °'.c' .F.. ...E.-n. a• .." ' _ - .. .. 'i. i�."�".'i-^..= S e _ ... _ .