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HomeMy WebLinkAbout0335 PLEASANT PINES AVE - Health E Pleasant Pines Ave ville 14 005 t I S / aEauFa mo UPC 12543 a No. 53LOR °�4isr.co °�� HASTINGS, MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` 335 PLEASANT PINES L1 I y FS Property Address POLICE 2 ` L�. Q Owner owner's Name information is ����� required for C ILLE q __�d�!._ r � MA 02632 12/15/07 every page. Cdy/I own State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A. BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A. BROWN INC Company Name it, Nb P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address-and that"pe information reported below is true, accurate and complete as of the time of the inspj4ion. Thainspeetion was performed>based on my training and experience in the proper function and ma r'tdtt nance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to ion 140 Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Soorgnature 12/15/07 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. Title V Inspection Form.doc•08= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 335 PLEASANT PINES Properly Address POLICE Owner Owner's Name information is CENTERVILLE required for MA 02632 12/15/07 every page. CltyrTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MEETS MINIMUM REQUIREMENTS AT THIS TIME , I CAN NOT PREDICT FUTURE PERFORMANCE 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 Title V Inspection Fonn.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is CENTERVILLE required for MA 02632 12/15/07 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is CENTERVILLE required for MA 02632 12/15/07 every page. Cltyrrown 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 ❑ ® 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. I ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 12/15/07 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 15 r Commonwealth of Massachusetts Title 5 e Official Inspection Form Subsurface ace Sewage Disposal System Form- Not for.Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 12/15/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ 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)] Tinto V Inc rljtyt Fym,r ,q%J1fi Ti1MW(1IpMSM•IMNRiR?Fth-A,p SNY:CSTKcIiFF'ar`a'.Ce`w'arib ITicrSncal:CJc�om'.da`ri';�'�{ 'S I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is CENTERVILLE required for MA 02632 12/15/07 every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 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 years usage(gpd)): Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): I Title V Inspection Fonn.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 every page. City/Town 12/15/07 State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: B.O.H AND OWNER Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): TANK AND TWO LEACH PITS NO D-BOX Approximate age of all components, date installed (if known) and source of information: 1984 OFF AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Tide V Inspection Form.doc•0&06 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 8 of 15 r— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Volu ntary Assessments t 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 every,page. Cdy/Town 1 7 State Zip Code Date ate of of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 30" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) � If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -- ----------------------------------------- -------------------------- Dimensions: 1000 GALLON Sludge depth: 0"PUMPED IN 11/07 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0" PUMPED IN 11/07 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? TiHa V Inc ...........__.........,__....y_..._,._..........�... _y__., ._ TiHa 5 rlffinim In-4inn Fnrm-,%th—rfana.R w—rlicnncal.q_4_•panes p of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y � 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 12/15/07 every page. City/town State 2i Code P 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.): NO RECORDS AT B.O.H OWNER SAID TANK WAS PUMPED BY ACE PUMPING IN NOVEMBER OF 07. TANK IS VERY CLEAN AT THIS TIME. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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): � Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 10 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y` 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is CENTERVILLE required for MA every page. City/Town 02632 12/15/07 State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No 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 N.A 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.): NO D-BOX Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V Inspection Form.doc•08/06 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 12/15/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NEWEST PIT HAS ABOUT 11" USABLE SPACE AT THIS TIME, SYSTEM PASSES WITHIN MINIMUM REQUIREMENTS. Type: ® leaching pits number: 2 ❑ 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.): NEWEST PIT HAS ABOUT 11" USABLE SPACE AT THIS TIME, SYSTEM PASSES WITHIN MINIMUM REQUIREMENTS, I CAN NOT PREDICT FUTURE PERFORMANCE OF SAS. Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 12/15/07 every page. Ci mown State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 V . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 12/15/07 every page. City/Town State ZipCode 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. � 51 S`► a Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 14 of 15 ✓ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 335 PLEASANT PINES Property Address POLICE Owner Owner's Name information is required for CENTERVILLE MA 02632 every page. Cityrrown Zip 12/15/07 State Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 25' 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: OFF PREVIOUS TITLE FIVE INSPECTION DATED 2/05/98 BY J.P MACOMBER. ride V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 a Town of Barnstable F INE Tp� Regulatory Services IARNSTABLE p; Thomas F. Geiler, Director 9Q i6 9 1�0 vA,Eo,�yA Public Health _Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL A=F�FAIUR _ DEPARTMENT OF ENVIRONMENT 4`PROTECTId. ONE HINTER STREET. BOSTON, MA 02108 617.292.5500 MqR 19 TRUD1'CO: Gave riot F VELD 96) C4 StCTCL Govcmor � �nF�'°9, ARGEO PAUL CELLUCCI � DAVID B STRL' Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'f1l(ONJORM pJ Commissiol PART A CERTIFICATION r x Property Address: 335 Pleasant Pines Ave Cent. Address of Owner: 617 Main Street Date of Inspection: 2/5/98 (If different) Osterville,Mass . Name of Inspector:Joseph P.Macomber Jr. 02655 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 CentPrvi 1 1 P,MaGs _ 09632 Telephone Number: q()8=77 5_Z Z Z p CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: /Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fail Inspector's Signature: i Date: The System Inspect hall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to tf)e system owne and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303 Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upo, completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, o, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, o the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tan► failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: httpWwww.magnet.state.ma usidep 0 Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 335 Pleasant Pines Ave Centerville,Mass. Owner: Edward Kneale Date of Inspection 2/5/9 8 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced AL The system required pumping more than four 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 C3 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /U b Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: AZ/ 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance/J�(approximation not valid). 3) OTHER ? (revised 04/25/97) Page 2 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 335 Pleasant Pines Ave Centerville,Mass . Owner: Edward Kneale Date of Inspection:2 5 98 D) SYSTEM FAILS: You must indicate ei;• er "Yes" or "No" as to each of the following: Na I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303 Tne basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cone, the failure. Yes h� Backup of sewage into facility or system component due to an 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. Ala.(/fE Static liquid level in box above outlet inven due to an overloaded or clogged SAS or cesspool All Liquid depth in�qol is less than 6" below invert or available volume is less than 1/2 day floes. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($). Number of times pumped , Any ponion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any ponion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supple Any portion of a cesspool or privy is within a Zone I of a public well. Any ponion 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 n, acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: V40 The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply L7 the system is within 100 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 Il of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information (revised 04/15197) Y&g• 3 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 335 Pleasant Pines Ave Centerville,Mass . Owner: EDward Kneale Date of Inspection:2/5/98 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No i -K/ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components,.extluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _ The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) (revised 04/25/97) Peg* 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 335 Pleasant Pines Ave Centerville,Mass . Owner: Edward Kneale Date of Inspection:2/5/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow. 41 R.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents Garbage grinder (yes or no): tl Laundry connected to system (yes or no):�CS Seasonal use (yes or no):A&) /� tiD Water meter readings, if available (last two (2) year usage (gpd): �eu� U),4JQJ^+ JA4"' we4l Ah S Sump Pump (yes or no):220 �sT��idu �rr�y b'�Q�r'C Last date of occupancy:1AX COMMERCIALIINDUSTRIAL: Type of establishment: / /� Design now: A2,4gallons/day Grease trap present: (yes or no).9)-4 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: OTHER: (Describe) AJ Last date of occupancy: GENERAL INFORMATION PUMPING PyIXORDS and sourC of inforrSati System pumped as pan of inspection: (yes or no) If yes, volume pumped: A10 gallons l Reason for pumping: Qj�1j �e SDhll/J `fQYs TYPE OF SYSTEM _Ac-� Septic tank/44o44r3"w box/soil absorption system w//) Single cesspool A,0 Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: � a� �NS � r >T"G(�9�` �%t/5��.1 � i� 69��, s a ^5 awl, ?A`/J'l,9co m�°� Ste/ . Sewage odors detected when arriving at the site: (yes or no)2�_d (revised 04/25/97) Page 5 of 10 I - I i N--.-j it nEW THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH L /r ,.. ........................... M1111o,sttl or �u otritrtiun ermi Permission is hereby granted.... � ... .... ! ............ ._.... to Construct or.We '.� S � nd'v' ual S , r ge Di osal S emat No..._ . .. .....1 .... �L�`2�.... ................................. Street _ I as shown on the application for Disposal Works Construction Permit o.�.-'.. --------1 ated.......� . . .......... .�� �: ..................................... DATE. F ..................... Board of Health FORM 1299 A. M. ULKIN, INC., BOSTON THE COMMONWEALTH OF MASSACHUSETTS y� BOARD OF HEALTH ;,�d .........oF...... �,� / . . ... ................... Tlerfif irtt#j� of (gomplittnrr THJS I�T ERTIFY�hat he In ivid SewageD al System constructed ( ) or Repairedby........`.✓s..�•''� � .---..�. .� ----.. AI.e.............. ... .. ....... .. �I Iler has been installed in accordance with the provisions of TI�;E, 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........_5.4t .........3r�!)...... dated.....Y.//.5.1g4...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUN TION SATISFACTORY. DATE.................... . ... ................................. Inspector..... �.-..............................-•---•---........----•---.... BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT B P.O. BOX 427 Of �ysa� SUPERIOR COURT HOUSE o �! BARNSTABLE, MASSACHUSETTS 02630 PHONE : 362-25-1-1 EX`?'. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a straight faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not (ill bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is S25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7-10 business days. Results will be sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS M TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS. THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCURATELY PERFORMED PLEASE COMPLETE REVERSE SIDE OF FORM PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING THIS FORM BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT 362-2511 X 337 DRINKING WATER ANALYSIS LABORATORY SHEET Name Sampling Date: Time: Mailing Address: Sample Location: (Street or Box) (Street) (Town or City) (State) (Zip) (Town) Telephone: Year House was Built: Bottle Identification Number: Well Depth Feet (Taken from Bottle) Reason for testing (Check one): ❑ suspect a problem ❑ required by DEgE ❑ for information only ❑ new well 0 real estate transaction* .D'other: Note*: Some banks and mortgage companies may require additional testing which costs more and requires more water. Check with Lab before bringing in the sample. Distance of supply from possible contarrxination sources (check all that apply): -4- septic tank / cesspool _ feet Cl farm feet ❑ salted highway feet ❑ buried fuel tank feet ❑ land fill feet ❑ other feet Treatment used: ❑ none ❑ water softener ❑ filter SIGNATURE OF SAMPLE COLLECTOR ❑ Well Driller ❑ Owner ❑ Realtor ❑ Tenant ❑ Other ------------------------------------------------------------------------------------------ - FOR LAB USE ONLY - .—Total p form / 100 ml pH Conductivity (micromhos / cm) Iron (ppm) Nitrate- Nitrogen (ppm) Sodium (ppm) Copper (ppm) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 335 Pleasant Pines Ave Centerville,Mass . Owner: Edward Kneale Date of Inspection: 2/5/9 8 BUILDING SEWER: (Locate on site plan) .v Depth below grader Material of construction: Zcast iron Z PVC _ other (explain) Distance from private water supply well or suction line e6v Diameter V// Comments: (condition of joints, venting, evidence of leakage, etc.) e © SEPTIC TANK:,[ (locate on site plan) If Depth below grader Material of construction: / concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age "is age confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth Distance from top of fudge to bonom of outlet tee or baffle:_ Scum thickness: Distance from top of scum to top of outlet tee or baffle: J Distance from bonom of scum to bolt of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, conditi of inlet and outlet tees or baffles, depth f q id level in relation to outlet inven, structural inte rity, evidence of leakage etc.) ' :s 1.c�i�-� �ii/.�it' r �P'Fis iy GREASE TRAP:�di1i�� (locate on site plan) Depth below grade: /10 Material of construction;,�concreteVAmetal,VAFiberglassva Polyethylene oC&ther(explain) ,C/IQ Dimensions: Scum thickness: AI Distance from top of scum to top of outlet tee or baffle:Azo Distance from bottom of scum to bottom of outlet tee or baffle: -IV4 Date of last pumping: - Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inven, structural integrity, evidence of leakage, etc.) r /S /Ld re (r•vi••d 04/25/97) ?•g• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 335 Pleasant Pines Ave Centerville,Mass . Owner: Edward Kneale Date of Inspection: 2/5/9 8 TIGHT OR HOLDING TANK:x/a44 ljank must be pumped prior to, or a( time, of inspection) (locate on site plan) Depth below grade: 44 Material of constructionwA concrete tL4metal.V.4Fiberglass,V/APol�,ethylene,eAother(explain) _ 4111A Dimensions " Capacity: A)/9 gallons Design ilo"= gallons./day Alarm level. A14 Alarm in working order,V,, 1'es;41A Nu Date of previous pumping. .4Jj _ Comments (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:d?b4je . (locale on s!le plan) Depth o: licuid level above outlet invert: 1121� Comrnen:s (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHA�NABER:Ab,ljiC (locate on site plan) Pumps in working order: (Yes or No)�/� Alarms in �,orking order (Yes or No)'ZOZ Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r.v:..d 04/25/97) P.g. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 335 Pleasant Pines Ave Centerville,Mass . 02632 Owner: Edward Kneale Date of Inspection: 2/5/9 8 SOIL ABSORPTION SYSTEM (SAS):z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length:--- leaching fields, number, dimensions: CtJ overflow cesspool, number: Alternative system: Name of Technology: Comments: (note conditionrpf soil, signs of hydra lic failure, level of ponding, condition o veget tion, etc.) CESSPOOLS: (locate on site plan) Number and configuration: A119 Depth-top of liquid to inlet invert: /y/? Depth of solids layer: A-4 Depth of scum layer: A)h Dimensions of cesspool: 'V? Materials of construction: ltI Indication of groundwater: 107 inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) P R I VY: �/.� (locate on site plan) Materials of construction: Dimensions: AJr Depth of solids:�� Comments: (note condition of soil, signs of-hydraulic failure, level of ponding, condition of vegetation, etc.) (revlsod 04/25/97) Page B of 10 l�1 SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 335 Pleasant Pines Ave Centerville,Mass. Owner: Edward Kneale Date of Inspection:2/5/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) vJE,I� r/, / to - � 17 odd - (revised 04/25/97) Page 9 of 10 „ e LJ ����1SA/4 Arh �. SUBSURFACE SEWAGE DISPC -L SYSTEM INSPECTION FORM I C SYSTEM INFOL ... :ION (continued) Property Address: 335 Pleasant PInes Ave Centerville,Mass. Owner: Edward Kneale Date of Inspection:2/5/9 8 Depth to Groundwater;Iq Feet Please indicate all the methods used to determine High GroundwaW EIV.a;ion: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basemtr*sump etc.) �etermine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records heck local excavators, installers Use USGS Data Describe in your own words how you established the High Grounciwa-verElevation. Must be completed) We used groundwater contours map. Gahrety& Miller Model 12/16/94 (z.v1a.0 01/25/97) Pac. of 10 r-•nrzr+•—nira--Trnr—lrr.•nrrrnr�n-rerr.rr..r.:-.�.•r:rorr:warrernrxer.ts +av�m rrn *T�*a��r�-�r—�—..-.,._...' I TURN OF Barnes abl [BOARD OF HEALTH SUI)SURFACF SF.WAGF DISPOSAL SYSTEM INSPECTION FORM - PART U - CEf('IIFICATION �•••T. T ...—T.t`^.�T.T.T.n•R.'T•ITT.ST.it7Trt'.r.'1�1t'ni'7 T'Rar T.RRR'Vail"�'�fTTCr7 ITIInTR1T.T.s4�Tm•I7rr+r.:�.•rr. I^•�. —. -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 335 Pleasant Pines Ave Centerville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # �i �� d OWNER' s NAME Edward Kn2ale PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Seyti ' Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City Stat• iIP COMPANY TELEPHONE ( 508 } 775 3338 FAX ( 508 1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage dieposa7 system at this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : _12L/Sys teui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection wilicll I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature11 X Date 2/5/98 One copy of this t.ification must be provided to the OWNER, the BUYER ( where applicable ) and the I3OAnD OF lIEALT'II. * If the inspection FAILED , the owner or"'operator shall upgrade ' the eyotem within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CFIR 16 . 305 . partd .doc ,l 5 w 9 � v ti s s _ b 111 � THE COMMONWEALTH OF MA.SSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KN O WN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatiQns as required and is hereby authorized to use the title CERTRiU D TITLE S SYSTEM INSPECTOR as provided in 310 CMR 1 S.340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. Acting Dircctor of the1V21cr F'ollutioo Control t�yt TOWN OF BARNSTABLE LOCATION A iei✓n5 SEWAGE # VILLAGEf�6✓1-�lY�i��i� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. N �s /�u�� SEPTIC TANK CAPACITY IWO LEACHING FACILITY: (type) kwc/%y4 J-2z)-S (size) NO. OF BEDROOMS S BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: '44K/� akry6z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 2- S r , 51� o 74 llq ASSESSORS MAP N0: 2/ PARCEL NO.: .E M t T NO. 9NSrALL 'S NAME � � VD'AE' SWid- r DA. T E COMPLIANCEC i 5 S U E D Weil 170 r , Fs / THE COMMONWEALTH OF MASSACHUSETTS BOARD QF�9HEALTH ........7aav...........OF......./.�.�XW.57 .................................. Appliration for Uhip sal darks Tatuitrur#inn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System ....... --- ---- ... - ... .... ....- . .. ...• ..--..... ...--- --.. —Lo afo -Addr or Lot No. �3 ���.�.....�:�. . ---------------------------------------------------- _._ _ ner `` ll ................................................... Address 0 _ Df �................... Installer Address d Type of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms........................................... p ( )Showers g Cafeteria ( ) Other—Type T e of Building ............. No. of persons Attic Garbage Grinder Pa yP g ---------•---- P ( ) ( ) P4 Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity............gallons Length............... Width................ Diameter_______-_-__.._- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet....._.............. Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -••----------------- --------•--....................------......----------....-----•--------.........•.................................................. O Description of Soil...____ _ . -----•------------------------------------------•-------------------------------------....--------•---•-----•-•------ ------ s �—Answer when aPPlicable___-__U Nature of Repairs or Alterations ------------- ----------------------------------- ---------------------------------•--•-----•----------------•------------......-•---.........---•------------------------------------....-----•-•----------------------------------------------.....---•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System_in accordance with the provisions of I'111 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a tificate of Compliance has been issued by th oard he It Signed ............... r-- ---- .. ..--- ----•---- •---�---.._ `., - Date Application Approved B . = :........ ..................• f� Date Application Disapproved for the following reasons:.............................................................................................................. --------------------------------------------•--------------•---------------------........------........-----------------------•-----•--•----•-------------••-•--•-•--•-•-------•-------•••----....------ Date Permit No..... .. - -: Issued. --------------------------- --- Date THE COMMONWEALTH OF MASSACHUSETTS 6f� , BOARD OF HEALTH _..-....,. ,J'JM W.....--.---.OF..... !,. Appliratiun for Disposal Works Tonstrurtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systelm t. ............. Locatign Address / „ A ,�e� } •• or Lot No. .... °... .«.. t. �'!�� ....t ..�._ !J j t!............... � N.��F...... ......................... ...................... Wj owner •Address ............«.«..... .._...r. ..:�.L"6 X w'�1: fr" /� i ' .................................................................................................. .......... -y---..e -.-:._...s...:c..�................ Installer Address Type of Building,," Size Lot............................Sq. feet Dwelling jkf No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .. Design Flow...............:........:...................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) . Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a O Description of Soil...:y., .: y. ..........................•--.........------......-•-•-------........--••---•---......---•-----.....----•-•--........••••--.............. V ,--------•----•------------ •------------ x •••-••-•-•-•------------•--•-•----•--•----••--•••--••------•-••----•-------------------••--......••---•.............----•------•----•••••. . •••....---------------............------. U —Answer when applicable-.__._,f y __ ........................................................... Nature of Repairs or Alterations ... •. .........................••----•••••--•••-••••••--------•--•-•••-•-••-•--••••--•--•••••--•..........-••--••-•--•---••.......---......_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by thg+boardf health. 1��"�eSigned -•��'< •<.°�_.�.. t.f ... ..tw a t. f�4%" � ✓ // - _, . = r&A ....... 5 « Dat Application Approved By............:. •--•.. .... ................... ',� ...-----•-- -----. .......... ... Date Application Disapproved for the following reasons:...........................................................................__.__...._.______.•__..........._-- ...........••••••-•---••-•----••••--•--•--•................•••----••••-•••-•--•.....----•--••••-----...«...---•••--•••..........---•...••••••---•--•••---.....--••••••-•--...--••---••-...............« _ Date PermitNo..- -�-------- --------«..« Issued....................................................... Daft THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '* ry '.? ...... .OF.... A ...................... d9rrtifuttte of Tumphaurr THIS IS TO CERTIFY,,,That the Individual, Sewage Disposal System constructed or Repaired y. ... - -- -... :.. .�1 - ,1.:................................•---•--.......---...•••... -«....« ' s r4' x fF7r�Installer *-aaue ... ._.. SS✓ ° wE' -------- atfi'% .✓.... ! f ..«. /F JY w.+�a ................. has been installed in/accordance wit the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... �.o..._':... 1....... dated.... y �s1a'�----------•----------- THE .ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................� 1 G --.......... ........ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........,OF...... ';y ..................... r, No .. Fsi�...: :..« ...... . Disposal Porks Tonstrnrtion ,,permit_. o Permission is hereby granted :` '°Z �' f : -c r • �,_.:..1. .......�?.e. s c.........................«««.. to Construct ( ) or Rep ` ` ( , Y an Inndwidual Sew`,ige Disposal System at NO_. "�"' - w: u�¢✓ f . :F.�`r .._ ,r'��!�....__. . � ..... ........... treet as shown on the application for Disposal Works Construction Permit o5...... Dated......o- 6........... Board of Health DATE..r .t,........�ft�4'�...................... FORM 1255 A. MLKIN, INC.. BOSTON 'vr�