Loading...
HomeMy WebLinkAbout0021 PLEASANT PINES AVE - Health LOT 1A PLEASANT PINES AVE. 4*1�CENTERVILLE A = 233 050 /IlI /f J�FECY�C�UCO z UPC 12534 No. 2-153LOR $Fosr.ccNs�`�` HASTINGS, MN I Z , Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 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. Inspector Information Sl# 65a. w on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. Q Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes "I"OF�Mgs4i��i 2. ❑ Conditionally Passes `;•�ya�. " .,sy�.,�� MICHAEL yN 3. ❑ Needs Further Evaluation by the Local Approving Authority °o: SEARS No.SI14430 y 4. ❑ Fails ;* a cFRTIF�� F ' iN 'C, 3-24-21 Inspector's SignAld1fie 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 x r Commonwealth of Massachusetts �. IF Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. City/Town State Zip Code Date of Inspection' C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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 is in working order 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............ !% 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cost.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �n ►� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Pleasant Pine Ave u� Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... � 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. Citylrown State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2019- 85000gal g ( y g (gpd)) 2020- 83000gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy. NADate I� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L, 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 22"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, 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.): 1500 gal tank with in tee and baffle out in place inlet cover 13" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �n ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Pleasant Pine Ave v� Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 21 Pleasant Pine Ave V� Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 1 outlet pipe, Box at 37" and cover at 10 below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 °y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate 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 I Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 1000 gal pit, pit has 2' of water and no sign of failure 12. 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 layer Depth of scum la p Y 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r cam, Commonwealth of Massachusetts �- Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�, 21 Pleasant Pine Ave V� Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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-rev.7/26/2018 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 21 Pleasant Pine Ave_ i Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 i i i r,;0,V 1 ( A I I I � I } i j� RC n -01 f? :;i �J 'r 'd1r• � r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 21 Pleasant Pine Ave • u� Property Address James Eldredge Owner Owner's Name information is required for every Centerville Ma. 02632 3-24-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: System is in front yard, back yard drops off 20'+ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form M1� Subsurface Sewage Disposal System Form- Not for Voluntary Assessments .�� 21 Pleasant Pine Ave ._ Property Address James Eldredge Owner Owner's Name information is Centerville Ma. 02632 3-24-21 required for every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of- ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 6�ad c to' --T ae4*a;v o-( Sys ao, 1a' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 s { l I , Commonwealth of Massachusetts � Title 5 Official Inspection Form iul Subsurface Sewage Disposal System Form Not for.Voluntary Assessments 21 Pleasant Pine Ave. . Property Address James Eldredge Owner Owner's Name information is. Centerville MA 02632 4/10/09 . required for 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.. Irri When A. General Information fillingng out out forms �2 on the computer, � use only the tab 1. Inspector: key to move your cursor-do not James D. Sears use the return key. Name of Inspector Bluewater r� Company Name 350,Main St Company Address West Yarmouth MA 02673 City/Town State Zip Code 508-775-2800 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the 'information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage-disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title.5(310 CMR 1,5.000).The system: y y;��N`OF'M ,�1�� �P S Passes x❑ Conditionally Passes ' Fails JAME, ❑ Needs Further Evaluation by the Local Approving Authority SEARS N 4/14/09 ktl/minitlttq���� spector'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 r8ppropriate 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. 9 / l 2f Pleasant Pine Ave Centerville.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 i Commonwealth of Massachusetts Title 5 Official lnspecti®n. Form +_I Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville MA 02632 4/10/09 page. Cityrrown State , Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B;C,D or E/always complete all of Section D A) System Passes: I ❑. 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:X ❑ 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 breakout 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 21 Pleasant Pine Ave Centerville.doc•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts RE- ____r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville MA 02632 4/10/09 page. Cityf.Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally.Passes(cont.)c distribution box is leveled orreplaced ND Explain: Distribution box walls are gone. Need to replace Distribution Box. Box is 16"X1.6" 38" below grade one line in one line out. Garbage disposal must be removed. ❑ 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 o#Health determines in accordance'with 310 CMR 15.303(4)(b)that the system is not functioning in,a manner which will protect public health, safety and the environment: . _ 4 ❑ 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. 0 The system has a septic tank and SAS and the SAS is within a Zone 1 of'a public water supply. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 21 Pleasant Pine Ave Centerville.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth. of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is Centerville MA 02632 4/10/09 required for every page. Cityfrown 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 copy of the analysis-must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than:'/Z day flow Required pumping more.than 4 times in the last year NOT due to clogged'or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. El 0Any-portion of cesspool or privy is within 100 feet of.a surface water supply or tributary to a surface water supply. y , 21 Pleasant Pine Ave Centerville.doc•03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System a Page 4 of 15 f \ Commonwealth of Massachusetts. G Title 5 Official Inspection Fora , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owners Name information is Centerville MA 02632 4/10/09 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ x❑ Any portion of a cesspool or privy is within.50 feet of a private water supply well. t El 0 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 DERcerti,fied laboratory,for fecal coliform bacteria indicates absent and the presence, of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprri, 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 El' 0 the system is located in 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. 21 Pleasant Pine Ave Centerville.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 , h� Commonwealth of Massachusetts l� _ J Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r ............ 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every. Centerville MA 02632 4/10/09 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 X❑ ❑ Pumping information was provided by.the owner; occupant, or Board of Health ❑ x❑ Were any of the system components pumped out in the previous two weeks? x❑ ❑ Has the system received normal flows in the previous two week period? El 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) , x❑ ❑ - Was the facility or dwelling inspected for•signs of sewage back up? Z ❑ Was the site inspected for signs of break out? . ❑ Were all system._com pone nts, including the SAS, located on site? o ❑_.. .. ._:. .. .. _ Were the septic tank_manhales 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: Z ❑ 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 El FX approximatiorrof distance is unacceptable) [310 CMR 15.302(5)] 21 Pleasant Pine Ave:Centerville:doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 h . Commonwealth of Massachusetts "NOR-,; Title 5 Official 'Inspecti®n Form 1 j,': Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r�d " 21-Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville MA 02632 4/10/09 page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions:- Number of bedrooms (design): 3 Number of bedrooms (actual): 4 DESIGN flow based on.310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ZYes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑Yes 0 No Laundry system inspected? ❑Yes Fx1 No Seasonal use? NYes ❑ No Water meter readings, if available last 2 ears usage d 08/29000 9 ( Y 9 (gP )) 07/26000 Sump pump? X❑Yes ❑ No _ _. . Presant.. Last.date'of occupancy: — Date Commercial/Industrial Flow,Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑Yes ❑ No Industrial waste holding tank present? ❑Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 21 Pleasant Pine Ave Centerville.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts r� Title 5 Official inspection Form �I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /•/ .21 Pleasant Pine Ave Property Address James Eldredge Owner Owners Name information i e required for every Centerville- MA 02632 4/10/09 . page. Cityfrown State Zip Code Date of Inspection D. System Information .(cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑Yes ❑x No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: x❑ Septic tank,distribution box, soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy ❑ ..Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and- maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1987 permit#87/571 Were sewage odors detected when arriving at the site? ❑Yes x❑ No 21'Pleasant Pine Ave Centerville.doc•.03/08 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts 1 - Title.5 Official Inspection Form isi- I-` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ . ......... 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is Centerville MA 02632 4/10/09 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 30" Depth below grade: feet Material of construction: ❑cast iron x❑40 PVC ❑ other,(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Camera line. No sign of brakes or roots. Line clear in good shape Septic Tank(locate on site plan): 2311 Depth.below grade: feet Material of construction: L.concrete ❑ metal ❑fiberglass ❑.polyethylene ..❑ other(explain) If tank is metal,list`age: years ❑ Yes ❑. - Is age confirmed by a Certificate of Compliance? (attach a.copy of certificate) No 1500 gal pre cast . Dimensions: 21' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 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? Tape sludge judge 21 Pleasant Pine Me Centerville.doc.03/08 Title 50fficial Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 �1�7 Commonwealth of Massachusetts j Title 5 Official Inspection Form lei Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 uJ 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information i required for every. Centerville MA 02632 4/10/09 e page. City/Town 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.): Tank at 23" below grade with inlet cover,at 15" Inlet tee outlet baffle Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete Q 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): 21 Pleasant Pine Ave Centerville.doc-03/08 Title 5 Official Inspectidn Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts , s Title 5 Official Inspection For JP t6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is .required for every Centerville MA 02632 4/.10/09 page. City/Town State Zip Code Date of Inspection D. System Information (coat:) Tight or Holding'Tank(coot.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes.❑ No Distribution Box (if present must•be opened) (locate on site plan): Depth of liquid level above outlet invert At working 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.):: Distribution Box is 16"X16" 38" below grade. One line in, one line out. Walls are gone on box. Box needs to be,replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑Yes ❑ No :Alarms in working order: ❑Yes' ❑ No 21 Pleasant Pine Ave Centerville.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11.of 15 Commonwealth of Massachusetts u � Title 5 Official Inspection Form , �✓ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville MA '02632 4/10/09 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.)Y ( Comme nts i note condit ion ton of pump chamber, condition of pumps and appurtenances; etc.): X Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: Fx-1 leaching pits. number: 1 v 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 600 gal precast pit with 4' stone pit at 46" below grade with cover at 16". 2'water in pit. No high stain line. No sign of over loading or solid carry over. 21 Pleasant Pine Ave Centerville.doc•03/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15- Commonwealth of Massachusetts - 'v� Title 5 Official Inspection Form r� Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments wi 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville MA 02632 4/10/09 ; . page. CitylTown State Zip Code Date of Inspection D. Systems 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.): 21 Pleasant Pine Ave Centerville.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of:15 Commonwealth & Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments... 21 Pleasant Pine Av Centerville Property Address James Eldredge Owner Owner's Name information is required for every Centerville _ Ma 02632 4/10/09 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. LO 1. i G - 0 3 7' 3 - 3 3'-! Title V Inspection Report.doc.•03/08 A Title 5 Official Inspection.Form:Subsurface Sewage Disposal System-Page 14 of 15 , r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �k. , 21 Pleasant Pine Ave Property Address James Eldredge Owner Owner's Name information is required for every Centerville MA 02632 4/10/09 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope x❑ Surface water tip 0 Check cellar >/1 0 Shallow wells ,,,,�,_6 Estimated depth to high ground water: 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: 1987 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole on construction permit. No water at 11' 21 Pleasant Pine Ave Centerville.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitation for MispoBal 6pstem Construction Permit Gr Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a I Plek5a-# P'ne5 o je, Owner's Name,Address,and Tel.No.j u✓h�0 tt ,v.0- 6Zta3 .�r� t1er � a ► Pl cc�sa�4 ►�,hes av Z c4�t��,,:ale ,vtw Assessor's Map/Parcel �V r sp i- Installer's Name,Address,and Te.No.'Z56kso+t ►Z.ogcas Designer's Name,Address,and Tel.No. �� �31vA wa�e/� S,stj1�>Ln 10 iin W. ccQw�ostF `6 yZ3 `57`6 Type of Building: Dwelling No.of Belildi 3 Lot Size _'3 14t m 3 sq.ft. Garbage Grinder(Lb) Type of B No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 C5 gpd Design flow provided C/�- gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank `S 8O Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Ans er when applicable) Date last inspected: Agreement: The undersigned agrees o ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions o Title of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by his B a of Heal igned' Date s s O Application Approved by Date S' Application Disapproved y Date for the following reaso Permit N . Za0 q ' l Date Issued S ppp No. Z O Fee /O O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes flpfitatimi for ZIsposal *pstem Construction i3ermit Application for a Permit to Construct(/)(:Rfepair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components, FA ocation Address or Lot No. a1 Plea5u,i P,,e5 aJC Owner's Name,Address,and Tel.No,seVIA 6 ssor's Map/Parcel _ tJ"�� ®0 _ Sc,6- 3(oz—G ? A Installer's Name,Address,and Te.No. ��soy 1Zc5 c�5 Designer's Name,Address,and Tel.No. ' 131v6_w«k e.L Sk,pa:L 11 Type of Building: Dwelling No.of Bedr omr� 3 Lot Size _�J-i,c-o sq.ft. Garbage Grinder(Uj) OtTher Type of Building ' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '� gpd Design flow provided G!�- gpd Plan • Date Number of sheets Revision Date Title Size of Septic Tank 5 D Type of S.A.S. �(/Q y ��. /e c(, Description of Soil Nature of Repairs or Alterations(An s er when applicable) r Date last inspected: Agreement: i The undersigned agrees o ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions o Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B� ld of Health. / igned Date Application Approved by Date Application Disapproved by (� Date for the following reaso \/ Permit N G GI ' 1 i Date Issued S l S2 po THE COMMONWEALTH OF MASSACHUSETTS .. r / D y a ` BARNSTABLE MASSACHUSETTS (� Certificate of Compliance THIS IS TO CERTIFY, hat the On-site Sewage Disposal system Constructed(� a aired( ) Upgraded( ) Abandoned( )by�t_4U-1 Koq z s ill e w + at d 1�lek54 + �, Q 5 a✓ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Nod - I I dated Installer i �2 o,7.i s k 8/ ,�, J�, s e ¢, �'' Designer #bedrooms ` , U Approved design fl ' d gP The issuance of this perm it/s�hall not be construed as a guarantee that the system will fan.0.1fon as des ed. Date �n U"► Inspector ' 11,�✓. J1-� 1 I X l No. ,,G o 11\ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS rai Opstem Construction j3ermit Permission is hereby granted to Construct Repair( ) Upgrade( ) Abandon( ) System located at x� 1 t��e s �" f i, :_ s �✓e and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. `? Provided:Construction must be completed within three years of the date of this permit. ! / Date / �/ 2 G U �1 Approved by 1..., / // (" i / TOWN OF BARNSTABLE LOCATION �• �f' U II SEW # 7-s VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ) d M SEPTIC TANK CAPACITY S� ©LEACHING FACILITY:(tyPC) d (size) _ NO. OF BEDROOMS IVATE WELL OR PUBLIC WATER BUILDER OR OWNER?k4 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No � v NO.P .._....._..._... ( Fs$ THE COMMONWEALTH O MASSACHUSETTS BOARD OF HEALTH ...................OF....... �.... .. .. Appliration for Disposal Morks Tonstru#iun Prrutit Application is hereby made for a Permit to Construct (4or Repair ( ) an Individual Sewage Disposal System at ('15 ....._..... ------- ---------- -- --------------•---.-------------- -. .�__ ..._..---.... ...._.....- -- ,A w n-A ress ..or Lot No. .......................... ------------................._....__............_ ._ _...........-----------•--•-•-•-------: -----..........................................:._.. /� Owner Address W A�vA. ��- •---- - - ----•---••--•• -- ............................................... W -- - � � Installer Address Type of Building Size Lot.. ',005_..Sq. feet V Dwelling—No. of Bedrooms......... -Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures, .----•-------•• •--•---•------•••--•................_._. . W Design Flow....................5.�.................gallons per person per day. Total daily flow.......................4Q.G........gallons. WSeptic Tank—Liquid capacityf ..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width...._�_.......__... Total Length............... Total leaching area....................sq. ft. Seepage Pit No.........I.......... Diameter........ Depth below inlet....... t�....... Total leaching area..! ...sq. ft. Z Other Distribution box ( i� Dosing tank ( ) 11 - ] ~' Percolation Test Results Performed by..34..- .�- ►"`# --------------------------------- Date....l.�.r.�_1.Q4;?................. �7 Test Pit No. I.....�-......minutes per inch Depth of Test Pit.........11....... Depth to ground water..... °....__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---•---•••--------------•------•----••--.......-••-----•----••-•-•-•••--•--••......•-•-•---•----•--•......................................................... 0 Description of Soi1------------------------------------------------ - - --------•----------•-----------------------•----...-----•---------......----------••------------- x -•••-------------------•--------------------------•------•••---------------•---•--------- .. M _.----•-••.................................•--1.(d.4-�.__!N&A- _I1i.IP------•. W V Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------•---•--------------------------------•---......--....................----......•------•---•••-•--•-•--•-------------•----•---•-------•----•--•----••----•-•-••-••-------.................._•-•... Agreement: I . The undersigned agrees to install the aforedescribed Individual Sewage al System in accordance with the provisions of TITLE 5 of the State Sanitary Code— he undersi ne rther ees not to place the ystem in operation until.a Certificate of Compliance has been is e y the boar h Ith. 4 Signed .. . • ............. Application Approved By--- - ------ - ------- a ----------- -- ........ Date Application Disapproved for the f oll i g reasons:--------•---•-----------------------•--------------•---•--------------------------.....-•---•......--•-•••--.... ....................•----•---....----•-----------...--------------..........--•--------..--...----------•-••----••-----•••--------••-------••---•-•--------•--------•-•-•••---•••----•-.......-------••• 1 Date Permit No...... -4------•............... Issued............................................ a Date -- --- Fps...../... :�...1: THE COMMONWEALTH O MASSACHU-SEETTS . .......... ;-- BOARD_,OF.OF HEALTH 1 H t 1 r- �J ................OF.......1 �r.1:�'�.f..`.T'✓�-tom.t'...---.....---....._-----•---------•- Applira$ion for Disposal Works Tonstrar$ion Frrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: Location-Address _ or Lot No. ......................_... f1.��Cl �j ... U17 .(s ------- ---------•-•--•----• -•-------------_......................._... .. .. .. .. ---------------------------------- c� Installer ;' Address d Type of Building Size Lot_ ©�.—___Sq. feet/ U Dwelling—No. of Bedrooms__....... __ Expansion Attic ( ) Garbage Grinder ( v) Other—Type of Building __._ No. of persons____________________________ Showers — Cafeteria a' Other fixtures ...............•--•------••_-••- d w Design Flow..................... _ti.................gallons per person per day. Total daily flow__._..__.___._________�g1_G........gallons. WSeptic Tank=l Liquid capacityl_eSCD__gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length_.____.__._..___ Total leaching area....................sq. ft. Seepage Pit No.........f......___.. Diameter__.__...__. _..... Depth below inlet___.._2:_\.__..... Total leaching area__r1- - =_`-'___sq. ft. Z Other Distribution box ( I/� Dosing tank ( ) j `" Percolation Test Results Performed by. ��(Zl z�.-__+__ �� _____________......... ....•-_. Date-•• -E. i_tf Test Pit No. 1......�.":•_......minutes per inch Depth of Test Pit........._l_______. Depth to ground water......_"'______________ (i Test Pit No. 2........_.......minutes per inch Depth of Test Pit_______.____________ Depth to ground water........................ a ----•-••--•-•---•••-••--•------------••-------•-----•••----------------•.._..__......_......_------•......................................................... 0 Description of Soil...............................................v ---------------------------- �(�1 L �-��`n-------~'►a1.i� ---...-•••------------•..............•••--•--•-------•----- w -------------------- --------------------------------•----•-•--------------------------•-•-•-•--•----•---••--•--------•--------•-'---------•----------------•-•-------------------------•------•••-•---- UNature of Repairs or Alterations—Answer when applicable. .......................-----•••-------------•---•--•---•--•------•--------------._..........•-•--•-•---...------•-•-----•--••-•-----••----•----•-----._...___....------•--•••------•--••---•--•------•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage al System in accordance with the provisions of TITLE 5 of the State Sanitary Code— he undersi ne rther ees not to place the system in operation until a Certificate of Compliance has been is e y the boar lie lth. Signed ; •--- -•----------- ---f...... % L ./1v Cl . . Application Approved By---I�+� '='��. ...... = ` /'� ........... / i Date Application Disapproved for the f oll wig reasons---------------------------------------------------------------•--------------------------------------•------•-- -----------------•-•._.....--------•-----••-•---------------......_...---•.....•-•...-------------___.___.-----------•-•-•-••••--------------•-----------------------•---••-----•----•--••-••------------ �• - Date Permit No.----_;7 �— 5 -----•--------•----•--- Issued-..........................................Date ....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............(AA)1,...............OF........... ................. ................. Tntifiratr THIS I� O CERTI, Y, That the Individual Sewage Disposal System constructed I V, or Repaired ( ) - {-•--------- � �•tia ZA. ....... by-•--•---_-•-•••- " 7 l Insta Ilpr has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Coe as describeA the application for Disposal Works Construction Permit No.__.`)._-_:-._5_ __I_____________ dated__-...-_. -_Z .�.'.__?.�______• THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE� SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... ''1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r :...... ........OF............-.._..:. ...........-- ........................-..... No......................... . FEE........................ Permissio is hereby granted........... -— �---__-•r`� �l .j�t_�>� �=�� -----------------•----------•---•-------.. .. _.........-•----- to Construct ( ) or Repair ( an Individual Sewage Disposal+-5y�em d — G` / �. at No..... 1 -•----•--� ............ (! =? " = � ---- �h (­I� 1, at shown on the applicat' n f r Disposal Works Construction Permit tNo ..S-.�[. �� 2 -- Q Board of Health DATE (�-------------------- FORM 1255..HOBes & WARREN, INC., PUBLISHERS -T LOT CouUli �r *y OLC PN •'c: P?AX rEFI v; or . I All *-7 50/g7 -t so 8? J N IVU)l�ir. �(ISTI�IL T�L� CC+ I emo�I� . TAUK ' L=�llST1tJL S�ptlG .S�ST"E�V� Tv �� Q13��tDo►J� f� ;��.- �"���. - ,' �`�°� i Lr- 46, . v4 I L-Y t LDYJ I I a X3-�OV, dst r� G PD �.�._o �a o �t�� bispoi- Pir usr= /14S�00E �CTTOM AZE'A z IeE34 5,F, T,/-r L-- 2�►l.Y FLOW - 4 q S Car V C� `6 1..- 1�>� T�sT �. 4o I��p INV L�GN .- 4'L•S $OX P)T t �Q♦JK I�'._... �� ' v/rrN.� IL)V. IQN, /4-'To lY-Lr �a d2-] Lt-2•�� . `.�A►J�y STorJ� `'.� >=l�V.=3q ' T �7L J�Q t L - I"_ � 1�.TE d Wo WC--c�• L Av-e LOT t A IJo VJA-tt2._ �'Cl��J (viz �nti,, s a L�D2��GP L�.r� � S�t3i�7 I�OP's��� 5f tow N ,�xT NY�� 1�X L7/30/9,77 F=`! T}-lb"r TiIE 'Dv�t�u-I�G WlTH T"ET�l� iz1=QUIP-sm�.1TsOF THE or✓ 1: 1,4 17TN13(.� aqua ( s133 WtTI-�tN THt= F.�P pI N. TI-1 l5 t>t_A.)� !S t.i�rt' g,ASEU oN �,IJ 1 rJSTiZ-dv - �N�w►Vr SOu�b NQT 1'3>✓ ��SEb T4 PF SfA£5L15H LOT I-ItiCS,