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HomeMy WebLinkAbout0224 PATRIOT WAY - Health ?24 Patriot Way ' Centerville P 193 203 UPC 12543 No.5� 1LOR -CO HASTINGS,MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 224 Patriot Way, Centerville M - 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information o key to move your n the computer, I (aPWU use only the tab 1. Inspector: cursor-do not Troy Williams use the return key. Name of Inspector Troy Williams Septic Inspections Q Company Name 19 Hummel Drive Company Address South Dennis MA 02660 City/Town State Zip Code (508)385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of L U cNTitle 5(310 CMR 15.000).The system: rn ® ;Passes ❑ Conditionally Passes ❑ Fails Ci•.s.. ❑ 'Needs Further Evaluation by the Local Approving Authority L!- c'. U c �._ February 15, 2012 ham- Inspector's Signature( Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurf Sewage Disposal System•Page 1 of 17 J l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Patriot Way, Centerville M- 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or mores components as described in the"Conditional Pass" section need to be system replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): N/A t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Patriot Way Centerville M- 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 224 Patriot Way, Centerville M- 193 P-203 Property Address Connie Doolittle Owner owner's Name information is 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Patriot Way, Centerville M- 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15 2012 - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes 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 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11J10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Patriot Way, Centerville M- 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 ill Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °t 224 Patriot Way, Centerville M - 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane Hingham MA 02043 February 15, 2012 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 ears usage d 11=52,000 gals. g ( y g (gp ))' 10=48,000 gals. Detail: Sump pump? ❑ Yes. ® No Last date of occupancy: occupied Date Commercial/industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Patriot Way, Centerville M- 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: Pumped in 2004. 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: i I ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system es or no if es, attach previous inspection records, if any) ❑ Y (Y ) ( Y P Y ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lug 224 Patriot Way, Centerville M - 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank is original to home. d-box and leaching were installed on 1/18/01 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1811+ feet Material of construction: ❑ cast iron ®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.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: 20"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: 5'X9'X6' 1000 gallon Sludge depth: 4" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Patriot Way, Centerville M - 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2'8" Scum thickness thin layer Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, Inlet and outlet tee or baffle condition, structural Integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet&concrete outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage DisposalSystem•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Patriot Way, Centerville M - 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A aci N/A Capacity:ty' gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 224 Patriot Way, Centerville M- 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is g required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level 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 was found level and in working. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11N0 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Patriot Way, Centerville M - 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 chambers with stone ❑ leaching galleries number: 25'X12.5'X2' ❑ 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.): Chambers were found with 10"of water present. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 224 Patriot Way, Centerville M- 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is 4 Crooked Meadow Lane, Hingham MA 02043 February 15 2012 required for every g ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Patriot Way, Centerville M- 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane Hingham MA 02043 February 15, 2012 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r (-J w�-s Y 1 •ti yt- �.h O O ' c 6 3 G O 3 = 7Y / t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Patriot Way, Centerville M - 193 P-203 Property Address Connie Doolittle Owner Owner's Name information is required for every 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 page. CitylTown 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: 30.0'+ 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: 2001 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: SDW 252 Zone C 47.0' 2.2'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 13.0'. Hand augered 4' below bottom of leaching with no water found at a depth of 10.0'. Groundwater adjustment at the time of inspection was 2.2'. Bottom of leaching at 6.0'was found not to be located in the high groundwater elevation at the time of inspection. USGS groundwater map for Barnstable estimated groundwater at 49.0'. Before fling this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Patriot Way, Centerville M - 193 P-203 Property Address Connie Doolittle Owner owner's Name information is 4 Crooked Meadow Lane, Hingham MA 02043 February 15, 2012 required for every ry page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION , �"M See~\• i�%P, 193 PARCH ' '2- >.a 03 a 24 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name:: Owner's Address: c La Date of Inspectio Name of Inspect : (please print) Company Name. e Mailing Address: Telephone Number: CERTIFICATION STATEMENT `* v I certify that I have personally inspected the sewage disposal system at this address and that the information repnteJi below is true, accurate and complete as of the time of the inspection. The inspection was perfor ed basedion no-1 training and experience in the proper function and maintenance of on site sewage disposal syst ms. I am a Dl Pt 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: Date: d3�U 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. Notes and Comment ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 � r :•, Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: j - L<D Owner: Date of Inspection: . Inspection Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D A. System Passes: V I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes:. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved,by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a.complying septic tank as'approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will:pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: * 7 A ' Owner: Date of Inspection 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(I)(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 I 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 ifthe 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: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM-NOT IFOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) Property Address: Owner: p Date of Inspection: C;)/, aQQV- 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 J clogged SAS or cesspool d/ 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 'i2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion.of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but.greater than 50 feet from a private water supply well with.no acceptable water quality analysis. [This system passes if the well water analysis, performed at a.DEP certified laboratory,for coliform bacteria.and volatile organic compounds indicates that the well is.free from.pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria. are triggered.A copy of the analysis must be attached.to this form.] ! (Yes/No)The system fails. I have determined that.one or..more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correctthe 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the.system is within 400 feet of a surface drinking.water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II.of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304..The system owner should contact the appropriate regional office of the Department. 4 r ` ^ Paoe 5 of]I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address y Owner: Date of Inspection. Check if the following have been done. You must indicate"yes"or"no"as to each of the following: _ Yes `9 / Pumping.information was provided by the owner, occupant,or Board of Health l/ 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? _ZHave 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) 17-1 _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? (l Were all system components,excluding the SAS, located on site _�_ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? -Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no J,,'� Existing information.For example, a plan.at the Board of Health. c'/_ 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 y , Page 6 of 11 OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: elf .1 Date of Inspection:. ,4 OW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2. Number of bedrooms(actual)Ae—drobms): DESIGN flow based on 310 CMR 15.203 (for example: 11:0 gpd x# Number of current residents: Does residence.have.a garbage grinder(yes or no): (� Is laundry on a separate sewage system (��or no) d .[if yes separate inspection required] Laundry system inspected y s or no): Seasonal use:(yes or no): pZ��2p0© 03�31$"a Water meter readings, if av ilable(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy - �. o COMMERCIAL/INDUSTRIAI��& Type of establishment: Design flow(based on 310 CMR.15.203): gpd Basis of design flow('seats/persons/sgft,etc:): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL NFORMATION Pumping Records Source of information: Was system pumped as part of the fnspTciion (yes 9 no): If yes; volume pumped: gallons==How was quantity pumped determined?' - Reason'for pumping: TYP OF SYSTEM eptic 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 copyof the DEP..approval _Other(describe): pproximate age of all components,date stalle (if kno ) and,source of information: Were sewage odors detected when arriving,at the site(yes or no . 6 r Page 7 of I I ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (N/, l,4 Owner: Date of Inspection: /1 � lrC� BUILDING SEWER(locate on site plan) Depth below Qrade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction liner Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: ' (locate on site plan) tt Depth below grade: Material of construction: oncrete_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: X CP 1.GCS Sludge depth: Distance from iop of sludge to bottom of outlet tee or baffle: Scum thickness: `] , Distance from top of scum to top of outlet tee or baffle: ` I Distance from bottom of scum to botto f outlet to qor baffl „ How were dimensions determined: ° ,�,� Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evi nce of 1 akage, etc.): 74/z' 16Z7,A/ZA-4Z -�6 J GREASE TRAP:4AU(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): y 7 ' y Page 8 of I I OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: �y Owner: �f Date of Inspection:/Z it mac-/e z0o . TIGHT or HOLDING TANK:W' 4ank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass'____polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: 1/ (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 outle'Is equal, any evidence of solids carryover, any evidence of leaka-e into of out f box,&VC PUMP CHAMBER:1241ocate 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 Pace 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �iC�LL�B� Owner: Date of Inspection '(10' C? 60 SOIL ABSORPTION SYSTEM (SAS): 1" (locate on site plan, excavation not required) If SAS not located explain why,: Type b-Ieaching pits, number: leaching chambers,.number: 0 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. . 60V " . 1 "7` � /1 4 r CESSPOOLS:.kU(cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: .Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,.signs of 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.)- 9 Page l0 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �V d O ZAtl,y Guaty a¢ V Owner: / — Date of Inspection:U.4 eA--)cD/jf>S� 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. la 2 t� ' jai o �m b-6 f c )00 rp a i(or) . 10 Paae 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 G�?.,eh G(/l Owner Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to around water 6 feet Please indicate(check)all methods used to determine the high,ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) /Accessed USGS database=explain: You must describe how you established the high ground water elevation: 10 S 11 Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: �✓zq ��/ r�P �a vl� ����6C Lot No. Owner: ��® L f-eck0ress: y�— Contractor: 6pfhol� Address �s i/�l9 llS�`rY Wi- 4' Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date 7 month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well.................. Z�Z OB Water-level range zone ...................................................:. STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to 0 water level for index well ........................... month!/year `7 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 2B) d determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................................................................. Figure 13.--Reproducible computation form. 15 ivil � 7 ' I i I TOWN OF BARNSTABLE G+ LOCATION SEWAGE r VILLAGE ASSESSOR'S MAP& LOT /93 to '3 AY 59.�G INSTALLER'S NAME&PHONE NO. �y}�o�i�. �ot�S��a�4>✓ SEPTIC TANK CAPACITY 1,a X0L. LEACH NG FACILITY: (type) ca`Gt �� �6a�,��C (size) X,.gl X.?1 NO. OF BEDROOMS BUILDER O 0 R ocL � I PERMIT DATE: f-�S'o� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S� 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) ,y Feet Furnished by ✓�� �3�/ �Yqv i�?(, �6� la's � a',b � /J�� �I ,as" -��. �'r= ,. r. _� � No. 7�.� � �l.J�/J Fee �V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZppYication for ]Dt9;po9;a1 *pgtent Construction Permit Application for a Permit to Construct( )Repair(1/)Upgrade( )Abandon( ) ❑Complete System ©"Individual Components Location Address or Lot No. 7-,7—y j&/1 D/.' jW1 Owner's Name,Address and Tel.No. AfAssessor's Ma /Part ��° JD G�c1e 3- ly 4/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ®rho/ 41 1 Co#0T Type of Building: ' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(_40 Other Type of Building ec2No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 330 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank //�®�911' X%�S �Y 9 Type of S.A.S. Description of Soil l Z.S—�Y Z Sr�►'Z Nature of Repairs or Alterations(Answer when applicable) J /e-C27 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his o of ealth. Signed Date / 0 Application Approved by Date 1! S f Application Disapproved for the following reasons Permit No. ?GQ 1 — (00S Date Issued I/5)o U TOWN OF BARNSTABLE LOCATION o�1f y ,e,�y SEWAGE # VILLAGE rnzid—al/� ASSESSOR'S MAP & LOT 93 � INSTALLER'S NAME_&PHONE NO. /o�,�, I SEPTIC TANK CAPACITY ✓.oL0 6,,OfL f LEACHING FACILITY: (type) Jan ar j�w,4 //,." (size) f NO. OF BEDROOMS BUILDER O OFR�Z, 4��i� PERMITDATE: /--5-"0� COMPLIANCE DATE: Separation Distance Between the: � s� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet PP Y g Facility.(If any wells exist Private Water Su 1 Well and Leaclun on site or within 200 feet of leaching fkility) - V .. . . Feet Edge of Wetland and Leaching Facility(If any wetlands exist ' within 300 feet of leaching facility) Feet ,. r� ��, ..,:- �.,.• .. Furrushed by .. _ .:_J < i i i i O J P 9 fi of g.Ci° •s�/ yL•� 7 3 _ No. 7 , W� Fee R:. / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 0(pphratton for Otzpozal *pztem Construction Vertu Application for a Permit to Construct( )Repair( 1efUpgrade( )Abandon( ) ❑Complete System , Individual Components Location Address or Lot No. L� ���`r%D�� W(� �/ Owner's Name,Adddress and'Teel.No. Assessor's Map/Parce / iq3- 2U CeIllr° ✓1 Installer's Name,Address,and Tel.No. Designer's:Name,Address and Tel.No. Type of Building: k Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( 4-1 Other Type of Building -YeMo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /Z gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank e5ir/%$ 'Z et 9 Type of S.A.S. 2 —S Dd 9c��oh G6iQ.•r��,�. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,�I ��' ���fQ" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system - in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by tt is Board?of Health. Signed 7/r Date /� Application Approved by ��.(2J1�v����RL�--P Date Application Disapproved for the following reasons Permit No. 7001 - 00 S Date Issued 1/5 J o U --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS l 3-- W3 BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER Y,that the On-site Sewage Distosal System Constructed( )Repaired(✓)Upgraded( ) Abandoned( )by O/` Zr) l at Z. Z 41, !Leje" GeJQ y as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 70L) -CQS dated S Utp. . Installer Designer s4 Aa The issuance of this permit shall not be c`nstttru 'y as a guarantee that the system�I� fu ction as de ig e Date Inspector No. Zoos —�S --------��-------- /( / -7Q3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS &Zpool *p!tem Construction 30ermit Permission is hereby granted to Construct( )Repair( ✓)Upgrade( )Abandon( ) System located at 7 1-17171-Lr'iO1s Wa V G e#leA411//1— and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by_ C7/U SC ltie� h La NOTICE: _ This Form Is To Be Used For the Repair Of Failed Se -tic Systems. Only. _ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) C?. �0/,1_1211/19 �l, hereby certify that the application for disposal works construction permit signed by me dated /A/// / concerning the property located.at Z Z q h'J`tldl_S meets all of the following criteria:. 414he failed system is connected to a residencal dwelling only. There are no commercial or business uses associated with the dwelling. �/7"le soil is classined as CLASS I and the pe.;.oiadon:ate is less than or eauai :o :runutes per inci. 7he:e are no wetlands within 100 feet of:he proo_osei septic system +' :Here are no private wells within.1:0 feet of the proposed sez is s�sem. were is no increase in flow and/or cha nge in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less s than five tee,above the ma.�cimum adjusted groundwater table elevation. (Adjust the groundwater.table.using the F rimptor lif meth when applicable]..the S.A.S. will be located with 250 feet of anv vegetated w leachingficili 5 elands. the bottam of the proposed ty will not be located less than fourteen(lei)feet above the maximum adjusted groundwater table elevation, Please complete the following: C d A) Top of Ground Surface Elevation(using GIS information) O q B) G.W.Elevation ?J +the MAX High G.W.Adjustment. = 3 3 DIFFERENCE BETWEEN A and B ! �y SIGNED : DATE: [Sketch Proposed plan of system on back]. 4;haft raiders pert Ae_ '31 f- F. N AYOx ;:V , 1;' loe 1� oo s v /_ 7 T-(--D h/ Al l ti �� ems. L o T �.¢ S if C S E /A/S P /�.�IUL .yv�PYPrgy TS O V E S E <ti,- %o 13E Lc� c,G; TE � 7� � C) - ETZ _7GE _Sy'S �" . � C � BED2oON/S' E S / .ZD /A G l DES/Gn!; otiS. TZUC'5T yO/tiS D . � . p�O7�oFL G �, G F?L S 7- 0 A/ SEZ) LE (2 /19R o M F� r ^+T'+w1K 5 A I+T 'Q -r. • T T-r L.. 1 • �i I O�/ T��7 / 14=SULTs N n < a �atr�� - w� Y n� ��S"ooya/ P%r TD de rgnK � LOCATION 'r SEWAGE P MIT NO. 'If- VILLAGE n I N S T A LLER'S NAME i ADDRESS ti BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED `� ,7� IL Ih ul ' T NU a_sl� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Gv .........................OF....d� ! .�5 .¢b.. o-----------.........---..............----- Appliration for Disposal Works Tow3utution ramit Application is hereby made for a Permit to Construct ((/) or Repair ( ) an Individual Sewage Disposal System at: ....�ot'may r�.9 ¢s w� E ...... _......_.----------------'� - .C' .. ................................................. ocation ddress - or Lot o. Owner Address Installer Address Type of Building Size Lot.-/ ...`.�....��.._._Sq. feet U —,...� DwellingNo. of Bedrooms.__..�'_..ie...........................Expansion Attic (/O) Garbage Grinder (//41 04 Other—Type of Building je.& ......... No. of persons:-/hl�:e......... Showers (C�) ) — Cafeteria ('0 a' Other fixtures ................................. W Design Flow...........//a.......................gallons per person per day. Total daily flow...........3_.Z.G............._----gallons. WSeptic Tank—Liquid'capacity/0.60_.gallons Length.............•.. Width................ Diameter................ Depth................ x Disposal Trench—No._'1'......... Width' ... Total Length.'___.____ Total leaching area....................sq. ft. Seepage Pit No..........I....... Diameter............. Depth below inlet.-...... _______. Total leaching area..s9.6..../sq. ft. Other Distribution box Dosing t�o Percolation Test Results Performed b .__ ,/�O,t,•9 0� '� .•........................... Date.../.Y®. 1.2.,,_.& ? Test Pit No. 1....4.......minutes per inch Depth of Test Pit... Depth to ground water......4.............. G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................... p; .... --•----•-------------------------------------------••......._------........................................................ 0 Description of Soil_.G ......... !esol_.--------------------------•--••------------------------•-------------------•----------•--------------------.--------------- ........................................... ----------------------------------------------------------------------------•---•---'••-•-----•. ......... 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. Sign d ...........d A lication Approved B 'aa,, Date PP PP Y � 1' ate-p�--�-- Applieation Disapproved for the following reasons-------------------••••-• -•-------------------------•--------------------------------........._._..... Date Permit No......................................................... Issued...... ..— �.� Date e. 1 L i ................. Fps..�::.:��....�..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...----....' ........................OF................................................................................... ...._. Appliration for Dhipmal Vorkg Tonotrnrtinn ramit Application is hereby made for a Permit to Construct (L.,'°) or Repair ( ) an Individual Sewage Disposal System at: ... _ ----- fit`................ •................... ��.---! ' ------�-. .-------- .......... ............... —Location- dddress 7� or Lot, .-_._.... ....... ........................................... .........._..............__....__ ......... ......._. Owner j"9 Address W f�l=dJJRs � "l -v�rrs s >1 ,sty ............................ ----.-..--------------------•------------ .....�. .......--- ---•--_........._.....---•--..................---•-_..... Installer ...... Address J Q Type of Building Size Lot.--I--a_��': 41.......Sq. feet V Dwelling—No. of Bedrooms._._.".. .'................. .Expansion Attic (/60) Garbage Grinder (.Vq 44 Other—Type of Building ......... No. of persons:%'./e _"1'---------- Showers (z) — Cafeteria (" Q' Other fixtures .........---•--......-•••--••--• ..._ W Design Flow...........✓-"0........................gallons per person per day. Total daily flow............3-..`'�.......................gallons. 94 Septic Tank—Liquid'capacity,2*-2---gallons,,Length................ Width.... Diameter................ Depth................ Disposal Trench—NO.``... '......... Widthy_r,.�' ... Total Length.._'P' ........... Total leaching area....................sq. ft. . Seepage Pit No..........(......... Diameter............. .. Depth below inlet........(Z ....... Total leaching area..j�26....rsq. ft. Z Other Distribution box (j Dosing t ( ) ,�^ / > Y r Percolation Test Results Performed b .__._--__-_•---------- - - - -- Date...._.= _._.____._._...._..._.�...__.. --------•- - =' ' Test Pit No. 1____ -------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........................ D Description of Soil. .Slr .. ------------------------------------------------ --••-•••••--------••---•-•----....-•-------•-•-•-•----•-------••---••----•---•-------••-••-••------------•----------------•--•--------•••-------_--••- 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 TITILE 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. Signed......'.=" -_. / -Vi a.*-� ...............F.. --------•-•• ................................ ` late Application Approved By------./ � .. ... .G.�....... "- . Date Application Disapproved for the following reasons:............................................................................................................... ........-•..........................•---•-----•--------•-.........------•---•----•....---_--••----....._.••----------•-•------------••••---•----••--------•---•-------•----••--------•-----------•-_---- Date Permit No......................................................... Issued _ .& - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...1�./..................OF.......... . .. .. .......'............... ..................... (Irdif iratr of TOutph anrr THI IS'TO CERTIFY,/That the Individual Sewage Disposal System constructed ( '�_ror Repaired ( ) � ;. �by .... -�-•_. -------•-•-at j has been installed in accordance with the pr isions of TrILF 5 of The,/State Sanitary Code as described in the application for Disposal Works Construction Permit No'__<... a_...2. '..k ------------ da.ted_-_t-- PP P ✓ ,�-�--=-•�------------•------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT f.... � � ..........OF...... ..�"�..'A4'' ...*................. , No......................... FEE/........................ yi� rrrat ok r fitatrimrn [rranii Permi ion ereby granted`.... ........ ......... ..... ... 4......... to Con ct ) or,�teg �n I A.v r3. ua} Sewa e i o ystem . (µ I _'r at ¢, Street as shown on the application for Disposal Wo - � rks Construction Per No.....:._' _ Dated..r'" 'r'0.7..`�.............. 7� � Board of FIealth ............................... DATE........ = ............................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS K - 45, zeu � • r _ gyp: '9�0 � . .�trf�-��ffe- °ti p �'' 21 73 .. • � ems, � I � t .Q5-Yre /�8 • �?ir✓ �yiN av s�, T E S F . A 0 L. E R E S U L T S P E P- 7-O W IV R.E-COR DS 1 Jq^, t 5Cf7LE T � l./n/ I-qVr!:� / L /f3 L.E 1NSP A7 U E E Gi(J/ /P E i`�E N TS _. 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