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HomeMy WebLinkAbout0025 RACHEL CARSON LANE - Health 25 Rachel Carson Lane, Centerville IQ. UPC 12543 � No. 53LOR �g0S70;SJJ HASTINGS, MN Commonwealth of Massachusetts Al. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Rachel Carson ' rf Property Address Vincent Visco Owner Owner's Name information is y required for every Centerville Ma. 02632 11/24/2015 ='-�=' page. Cityrrown 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 A. General Information filling out forms 2 on the computer, S74 // J1/2 use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Inspector Name of Ins key. P Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address MW Mashpee Ma. 02649 Cltyrrown State Zip Code 508-280-3356 S13938 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 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/25/2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. �o �s t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 page. Cltytrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This home has a H-10 1000 gallon septic tank and two leaching pits 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. 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): L 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,••'' 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal,to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? Aefe- c re T�v i-c�JnJ4ry #dJ'A "BPS ;n , tc,N>< ❑ Yes El No Seasonal use? ��T� ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: in 2014 21,000 gallons were used and in 2013 15,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: Sept. 2015 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: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 is Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owners Name information is Centerville required for every Ma. 02632 11/24/2015 page. 6tyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 35" 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: 24" 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: standard 1000 gallon Sludge depth: 311 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owner s Name information is required for every Centerville Ma. 02632 11/24/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle apx. 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle apx. 51' Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept has a list of local pumpinq co Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El metal El 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•'r 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is Centerville required for every Ma. 02632 11/24/2015 page. Cltyrrown 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.): 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 `�1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is Centerville required for every Ma. 02632 11/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: TWO ❑ 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.): There are two leaching pits in series. The first one was apx. half full at the time of the inspection the other was dry.At the time of the inspection water was running from the home a toilet must be leaking. 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•' 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is Centerville required for every Ma. 02632 11/24/2015 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,•'° 25 Rachel Carson Property Address Vincent Visco Owner Owners Name information is required for every Centerville Ma. 02632 11/24/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately V_A �J A T I A 3.2 3 - 35 3 � 3.5- �/ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name information is required for every Centerville Ma. 02632 11/24/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet 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: I augered a hole to show five plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • ` <LCommonwealth of Massachusetts a W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•' 25 Rachel Carson Property Address Vincent Visco Owner Owner's Name required fn is every Centerville required for eve Ma. 02632 11/24/2015 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Gr�zL y �.u v 1 ISM �F �O lest v Pjie Tu 1S t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 126.83' o � o° ^��• / TANK 0 EX. EX. / LF DECK DWELLING 13�, 0 =V / 40 MIL POLY MEMBRANE �� Q-y01- 0 0 N 0 PROP. INGROUND 86.89, SWIMMING POOL \ /0 N 73 83, E SHED FENCE TO BE INSTALLED WITH CONFORMING LOCKS AND ALARMS SEPTIC SYSTEM PLOTTED FROM INFORMATION PROVIDED BY OWNER. BUILDER TO CONFIRM CERTIFIED PL 0 T PLAN MBLU 190-204 OF M4Ssq 25 RACHEL CARSON LANE �• c I CERTIFY THAT THE IMPROVEMENTS SHOWN a� ti� CENTERVILLE, MA .HAVE BEEN LOCATED BY A FIELD SURVEY. ROBB DATE: 5-29-2020 DRAWN: RBS SYKES H " ' JOB # S710 No. 35418 SCALE: 1 =40 DWG. CPP F10�� EASTBOUND Fss� /STE�`S��' LAND SURVEYING, INC. 5-30-2020 awo P.O. BOX 442 FORESTDALE, MA 02644 ROBB SYKES P.LS. DATE 508-477-4511 0 b 9 [� COMMONWEALTH OF N ASSACHUSETTS IN — EXECUTIVE OFFICE OF EwRONNIENT.AL AFFAI DEPARTMENT OF ENVIRONMENTAL PROTE ON 1 2 1997 _ ONE SINTER STREET. BOSTON. hl.a 0210E f l --'c_-E'Pt, �j H'Nppe ti pjTAB[p N %VILLI-k,' F t%'ELD �► L �'`'1 Govemr Se;re rr AQGEO PAUL CELLL'CCI DA`,'ID B STRL'11S Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Cnmmusiorrr-1 PART A CERTIFICATION Property Address: t;k5, •e` �•LSrs"' L�-'tGo.sTza. �tl�_ Address of Owner: Pt's6onir-3 D Cu..,,�. V-1r 1f:��..\•,<< Date of Inspection: (If different) '�o•` ��� i'> Name of Inspector: ECr- 1 am a DEP approvedd syste�ector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: i- re_i-i *" P's 4o`� Mailing Address p_6 ,c C - ytj4l�PP_Q H I © �6 C Telephone Number: r5-e;e, J l �- /(� 2 4V _ CERTIFICATION STATEMENT I cenrfl that I have personally rnsvecied the se\+aee disposal system at this address and tha! the miormation reponed below is true. accurate and complete as od the time of rnspec o-. The inspection Kas performed based on my training and experience in the proper function and maintenance of on-site sev,age d sr­osa !stems The system- Pastes Conc,1,0^a„\ Passes `•eec- Fume- !uat:on 5.vibe local .Approving Autnorrn 1� lr� Inspector's Signatu�i � �U` ,11C� Date: A I Z The Sys:e r Inspecto•,shat' submi: a cop\ of this inspection report to the Approving Authority within thrriy (301 days of completing this inspection. It the system is a shares' system o• hat a design floe` of 10.000 god or greater, the inspector and the system owner sh211 submit the repo to .he appropriate ree,or•.al o^ice of the Depanment of Environmental Protectror The vagina! should be sent to the system 0vvnmr and copies sent to the buye•, ii applicah!e, and the approving authorm I►ASPECTiON SUMNLAR1: Check A, B, C, or D A) SYSTEM PASSES: 1 have rot found any information which indicates that the system violates any of the failure criteria as defined in 310 Cate. 15.30.3. Any failure criteria not evaluated are rndrcaued below. COMMENTS: 0) SYSTEM CONDITIONALLY PASSES: One or more system components as descrit�ed in the 'Conditional Pass' section need to be replaced or repaired The s-,stem, u►x,n completion of the ml?lacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, 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 tattachedt indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratron, or Lint: 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. page 1 of 10 DE°on the world wine weD hnc rrwww magnet state ma uvaec PnnteC an Recycied Pam, I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES tcorttrn.,ad Sewage backup or breakout or high static water level observed inl�e distribution box is due to broken or obstructed prpetsl or due to a broken. settled or uneven distribution box. fF,e system will pass inspection if(with approval of (he Board of Health). Describe observations broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a yea due to broken or obstructed pipets). The system %%ill pass inspect ion ii(with approval of the Board of Health): broken pipeisi are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED SY THE BOARD OF H LTH: Conditions exist which reouire iunhe evaluation by the oard of Health in order to determine if the system is failing to prole the public health. saien and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH D TERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ., WHICH WILL PROTECT THE PUBLIC HEALTH AN1 SAFETY AND THE ENVIRONMENT: Cesspool or p•;\� is within 50 ieet of a su ace water Cesspoo! o: pri%\ ik %.ithin 50 ir-et of a 7brdering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOAR/NN LTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERM►NTS TI4.AT THE SYSTEM IS FUNCTIONING IN A MTHAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The syste r has a septic tank anbsorption system (SKIS) and the SAS is within 100 feet to a surface water supply nrtributary to a sunace water suppThe system has a septic tank anbsorption system and the SAS is within a Zone I of a public Hater supply well. The s;siem has a septic tank ambsorption system and the SAS is within 50 feet of a private water supply well The system has a septic tank a d soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private Hater supply well, un ss a well water.analysis for coliform bacteria and volatile organic compounds indwtes that the well is free from polluti from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. method sed to determine distance (approximation not valid). 3) OTHER 1:evieed 04!1S/!7) sage 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR`1 PART A CERTIFICATION (continued) Propert% Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Z es" or 'No' as to each of the following - I have determined that the system srolates one or more of the following failure trite ra as defined in 310 CNIR 15 303 The o a s for this determination is identified below. The Board of Health should be contact to determine what will be necessar tc can the failure. Yes No .� Backup of sev�age into facility or system component due to an overl ded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or su ce waters due to an overloaded or clogged SAS or cesspool Static !rou,d levei in the distribution bo- above outlet invert due to an overloaded or clogged SA-5 orcesspoo• Liourd depth m cesspool is less than 6" below invert or avails ie volume is iess than 112 day floc. Recu-red pumping more thar•. 4 times in the last year NO/ivy e to clogged or obstructed pipes NumLutr 0' limes pumped An, port:on o`the SOO Absorption Svstern, cesspool or ps below the high groundwater elevancir. Anti Po,!:On o' a cesspool or pnvv is wither, 100 f11f surface water supply or tributa'\ to a SUrIace orate• su,,^^Ik ._ An•, roiion of a cesspoo' or privl is �!thir a Zo public well. An', pe^ o- e, a cesspoo' o• priv ,s within 50 ferivate water supply well A.n, ro^.or o a cesspool or privy rs less than 10ut greater than 50 feet from a private supplk k"i• v:rth no acceptable orate, qualm analysis If the well has, een analyird to be acceptable. attach cop,, of Weil wane_! an21vsV4 f- cohiorm bacte"a %olatele organic compounds, ammonia nitrr.,gen and nitrate nitrogen. El t_APGE SYSTEM FAILS: You must indicate elthe, "Yes' 01 "No' as to each of the followi g. The 1pliOw rF Criteria aop'% t0 Ia'ge systems in add e i n to the criteria above The s�s!em sees a iacilm with a design f10�• oft ,000 gpd or greater (Large SN•stem; and the system is a signif,C threw t-- publrc health and safety and the environment becayse one or more of the following conditions exist Yes No the system is within 400 feet of a surf/cedrinking water supply the system is within 200 feet of a I,i ut.ary to a sunace drinking water supply the system is located in a nitrogen,sensitive area (Interim Voellhead Protection Area • WA) or a mmamrtd Zone It cf a public water supply well) The owner or operator of any such system shall b !ng the system and facility into full compliance with the groundwater treatment program requirements of 314 C^1R 5.00 and 6.00. Pleas consult the local regional office of the Department for further information. (r•vim•d 04/25/97) lap• 3 of 20 � a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARI B CHECKLIST Property Address: -.S Q` 0-L," Cs,-4 .,o,,,- Owner: a0`C�Cxvu�L` Dale of Inspection: Ski,, , Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following. Yes No _ Pumping information %,%'as 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 flo%% rates during that period. large volumes of water have not been introduced into the system recentl% or as pan of this inspection As built plans have been obta,ned and examined. tote if they are not available with N/A _ The facilm or d\%ellrng "as inspected for signs o'sewage back-up _ The sx'stem does not recers'e non-sanitary or industrial waste flow Xr The site %-.as mspecied for signs of breakout. 4 _ All s\stern components, excludene the Soil Aosorption System, have been located on the site. _ The se,,^t;c tank manholes were unco,.ered. opener, and the interior of the septic tank Has inspected for conditlo^. of baffies or tees, matena o` co^struct,on, dimensions, depth of liquid, depth of sludge. depth of scum. — The size a^d location o' the So,! Absorplton System on the site has been determined based or, ' The iac-lrtx o,.ne• ;ano occupants. ri dineren: trom oAnen were provided with information on the proper maintenance of SuMvriace Disposal S\stem. Existing rn,fo-matron Ex Plar, at F O H De:erm,ned in the field a am of the failure criteria related to Pan C is at issue, approxrmatron of distance is �T unaccea:ab*1e (15 302,31:b? (revimed 04/25/57) Page 4 of 10 SUBSURFACE SE�%AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIOti (continued) Property Address: Jai ' CP"a&o 'J Owner: !*-ao x A Date of Inspection: �j4iZ'r97 BUILDING SEWER: No (Locate on site plan) .Depth below grade Material of construction. _cast iron _40 PVC _other texplain! Distance from private water supply well or suction Ii Diameter Comments: (condition of joints, venting. evidence of leakage. etc.) SEPTIC TANK:_�K (locate on site plan Depth below grade , �r Matenal of consiructto concrete _meta _Fioe,g,ass _Polyethylene —othenexplain If tank is meta;. Its: ape 1 age cor.firmec b, Cep :1ca:e of Compi:ance _(lesNo Dimensions C.1,4 � Sludge depth % Disfance from top o: siudee to bon -- o' cute: tee o• ba,;e Scum thickness I rr Distance from top o' scum to top c` outlet tee or ba',e Distance iro-n bottom o; scu-n to boron of out)e: tee c• ba*,e _1 ,0 How dimensions s%ere dete,mined r%4YC Comments t uecommenda:ion ier pumping .cor•dit,cn o, in;e-'}nr'C OUtlet legs Or baffles, depth of liquid level in relation to outlet invert, stru:'tur� integrity, evidence of leakage. etc i V6��`:CU �V" �r?I1r- l ��J P TVC -4I'flKV<__1 r bV F 1 T_— --JrLucr calm .! '!Sol;1K 1_t t'n l I . u 1 -- GREASE TR.'%P:1,f1U (locate on site plan, Depth below grade Material of construction: concrete _metal —Fiberglass ,_Polyethylene —other(explain) Dimensions: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle- Date of last pumping Comments: (recommendation for pumping, condition of vilet and outlet tees or baffles.,depth of liquid level in relation to outlet invert, stru-tural. integrity, evidence of leakage, etc ; Ire ired 04/15.17) Page 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTE1-1 INSPECTION FOR.q PART C SYSTEM INFORM.ATIOti Properts Address: C—g-C'SO"t L_-v Owner: H Date of Inspection: r�ltL15"� FLOW CONDITIONS ESIDENIIAL: Design floes '7j90 e o.d./bedroorr io- S.a,.'S Number of bearooms Number o'current residents 0�. Garbage g•: der (yes or no' Laundry cor^ected to syste (yes or no'. Seasonal use Ives or no,.fd k"cater meter readings, if available (last two ;2 year usage tgpd): �Q Sump Pump Ives or no) lu� Las date or occupancy COMMERCIAUIND 'STRIAL• Type of establtshrr,en. Design fio%% �galions•da� Grease trap present ryes or no_ Industrial \'taste Holding Tani; Dresen; yes or no 'von-samtar% N2qe d,scnargeo to the T!;ie S system ;:es or no eater meter readings if a,ailab!e Las: dxe o; o OTHER: .De,cr;be last sate of occuoanc-. CE`EFLAL INFORNiATIW% PUNAPING*K,ORDS and source of rni rma; on _1 k)vY1 r�--c� 1't .t a } act - C t t•� System pumps- as par, of mspecvan. ryes at no If ves• yo)ume pumped ga!lons Reason for pumping TYPE OF SYSTEM f Septic lanL rdr!fs e�bw.rors-br�io�l absorption system Single cesspool ' Overflow cesspool Prey Shared system (yes or no! (if yes, artach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date instilled (if known) and source of information: Sewage odors detected when arriving at the site tyes or no) V36 (revised 04/25/9*7) Page S of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..M PART C SYSTEM INFORM. TION (continued) Propert,. Address: OK ner: Date of Inspection: TIGHT OR HOLDING TANK: 'Tank must be pumped prio to, or at time, of inspection! (locate on site plan, Depth below grade Material of construction _concrete _metal _Fiberglass s olyethylene _other(exp!ain) Dimensions. Capacity- gallons Destg-1 floes galions'da. Alarm level A:wrn in %%orking orde, _IYes. No Date of preysous pumping Comments (condition o' inlet tee. condi:ion o• ata,m, and floattc.( DISTRIBUTION BON: iioca!e on site p an. De:th of !iauid le%e' aocn e o;,,te. in�e•. CGm^ne^ts 1nve 1! level and dis:'lbJ;,or is eoua e'"ldenC_ o' solids carryover, evidence of leakage Into or out of box, etc.( PUMP CHAMBER:_ (locate on sue plan Pumps in working order. O'es or No- Alarms in working order (ties or No Comments: (note condition of pump chamber, cor;:f Lion of pumps and appurtenances, etc.) (revised 04/24/91) Page 7 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIA PART C SYSTEM INFORMATION (continued) Property Address: 0`S � �E`ao►�t Owner: �� � Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): g (locate on srte:plan, if possible, exca ,on not required, but may be approximated by non-intrusive methods, If not determined to be present, explain Type: leaching pits. numb?r.�(OX� leaching chambers. number:_ leaching galleries, number. leaching trenches. number length leaching fields, numbe,, d,-rension.s over.'tov, cesspool, number Alternative system Name of Tecnr.otog,. Comments to re condition o+so,i. sgns ci hydraulic failure. level of pondrng. cQnditilon,or vegetation, etr.1 S '0gL1► Lar�,s _ c �J ,1tq� `�'"tJ ,•uc �Z.r �r f t tip z__!r,Jr— dlirt, s j CESSPOOLS: _ (locate on site play Number and con.f!€::•a:•or. Depth-top of liquid to inlet inter, Depth of saLds lase- Depth of scum layer Dimensions of cesspoo+ Materials of constructto- Indicatton of ground•,%ate- rnflo« icesspool mc:st oe pumper as oar, of inspection'• r Comments: (note condition of soil, signs of hydraulic failure, level of pondfng, condition of vegetation, etc.) PRIV1•:_ Uocate 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 ) (revleed 04/25/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued; Propert,, .Address: as O'.dW&,J Owner:tA4r\Lva �{p Date of Inspection: 61 sL,`tl SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least tAo permanent reierences landmarks or benchmarks locate all wells within 100 (Locate where public water supply comes into house) } 1 2S \ 3)- (revise 04115!5-) Page f of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION !continued) Property Address: aS 'fv%-6v,-0 (0,,tncw-1 Owner: WdtyCAk') Date of Impection:��4Z��1 Depth to Groundµate!120 fee; Please indicate all the methods used to determine High Groundwater Elevation: Obtained iron Design Plans on record Observation c�Site lAbuRrng property, observation hole, basement sump etc.) Determine it from local conditions Cne,K µith local Board o• nea!tr Chec:. FE•tom macs Check pump.nF records Check local e\Ca�xo'S inS;alle'S L5P `5C rla•a r• Describe in n„-. p,pre; np-.. �o- the H tgh Groundµater Elevation. !Must bu completed r1 S, 14-� k, Izov_ved 01,'25'9'. Pago 20 of 10 l-o-- -low- -' � -SEW-Q C,E- P-E-R-MPT-1.-1-0: - ell - �6 5-U- -I-L D E R-5-1.1-ANl E A D-D R E-SS D-ACE-P-E-R-tut1T 1.55UZED -����� - _ - -�� ��� .. . • , � _.. g � � i ' .` �� �� No........ ---•• F:as... �............... ` THE COMMONWEALTH OF MASSACHUSETTS / BOARD HEALTH It,r/ ,. OF i .................................................................................. V. Poor'R7air Applicat `ris hereby made for a Permit to Construct ( ) an Individual Sewage Disposal System .. ys --•--- -- L a ddress or Lot No. / ,X ner Address w I o' nstaller Address UType of Building�� p -`' Size Lot----------------------------Sq. feet Dwelling !!—No. of Bedr ams_____....... - _.__._____Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Buildi ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtur s .`_ w Design Flow.................. .. dons per person per day. Total daily flow-- ----gallons. WSeptic "1'ank�—Liquid capacity _. allons Length................ Width................ Diameter_----...._...-__ Deptli._.._.---...._. x Disposal Trench— 0. ......... ____. Widt i. ........ ... ... L n ------------ _.. ptal leaching area-._.-__-_-__.____-.-sq. ft. Pit No____________________ Diameters ep be e 7- Seepage __.___.___. Total leaching area._____..__._______sq. ft. z Other Distributi box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------- ------ Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit-.-__-__-_.__._--_-. Depth to ground water.---------.............. w Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_._--- __--__---._---- Ix ----._..... ...... 0 Description of Soil--------------------- ------------------------------------ ------------------------- U .....................................-.......................................................................................... ------------------------------------------------------------------------ w VNature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage DisposA System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further ag es not to place the system in- operation until a Certificate of Compliance has been issue t board of gned.-. . •... .......... -•--- . ---• --- --- .......... Date Application Approved By------ -� -- . . ------ Application Disapproved for the following reasons:--•----------------------------------------------------------------------------------••-------ate----•----•-•.` -------------------------------------------------------------------------------------•-------------------'----...............................................---_---------------------------------------- Permit No. Issued .� 2. -� .. Date- " Date No.._-_....f..... ....... ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH At;l�� ...OF.......................................i................................................ Appliration -for Diiivviiat or 11 "trurtion Permit Application is hereby,,made for a Permit to Construct Por Re air an Individual Sewage Disposal System,4t: or ...... . ........... .... ........................................................... -- ------------ -: � ddr ess or Lot No. ....... .. . . . .. . ................. .................... ------------------------------------------------------------------------ caner.............. . .. ..... ..................................Address...................................................... hst Ile Address U Type of guiidin t Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms-________-- ______________________Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons--__________________________ Showers Cafeteria Otherfixtur ..... ................................................................ Design Flow --------gallons per person per day. Total daily flow._.___- -----3—C) flo ---gallons. P4 Septic 'F,-Liikr,L,iq'tiid capacitv'/jj��__ allorls , Length________________ Width_._.._.-...._.............. Diameter____-_ ----___ Depth---------------- Disposal Trench No ........... tal leaching area_____________-------sq. f t. Seepage Pit-No.... Pkei600g ej-A-6-.A-- -------m--- Dep .... otal leaching area------------------sq. ft. Z Other Distributio box Dosing tank Percolation Test Results Performed by......................................................................... Date___.._...__-_------------------___-----. a ,� Test Pit No. I................minutes per inch Depth of Test Pit_-________________-_ Depth to ground water_.-.-_..-___-_.-__-_---. ;M4 Test Pit No. 2................minutes per inch Pepth•of Test Pit____.____..____._.._ Depth to ground water-_-_________________--_- ; Description of Soil ---------­---- .... .. ------------------------------------------- - - ----------------- U -------------------------- -------------------------------------------------------------------------------------------................................................................................. (4 --------------------------I--------- ------------------------------------------------------------------------------------- ------------------------------------------------------------------- .,u Nature of Repairs or,-Alterations—Answer'when applicable._-_______________________ ---- ------------------------------------------------------------------------7----------------------------------------------------------------------------------------------- ............... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Dispose System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agr s not to place the system in operation until a Certificate of Compliance has been issue t board of liev- ned____ Date Application Approved By----------- d. A ... ........... / _e te_7...... te __/a Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued................................ ..................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 5 HEALTH ..... ..... ......OF.......... . ...... .............. wwrtifirate of T"ftlimplitturr THI I To, 6R.TIFY"Ilat the Individual Sewage Di osal System c cted or Repaired 0 --------------- .... .... ... ......................... ........................... ---W ---0 - . . . ...... ....................... by--------- . ........ t �6nstzoer 10V ........... ... --------- at. _P�a y escl has been installed in accordance with the provisions of -Article XI f 11i-ie State S, ry C.o-.de,as desc,Obed in the A ,05e � I'Works Construction Permit No_______________ ________._.__--- dated. ... I ....f application for Disposa -- --------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© A V�p WE THAT THE SYSTEM WILL FUPCTION SATISFACTORY. DATE......— 7 T. .. & 4� .................................................... Inspector...... ............ .. ......L.A. .... ...... ..Z.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ................OF...40C�� ....... 2.,�!-.-"--­- ........................ N ..................... FEE /0------------ Dinpviial Workii Tonidrurtion Permit Permission eels -or pair granted------------------ .........t.�.............................................. ............................................................. to ConsLr pair InXdi ,�i 'Segje Disposal Systenj .....Ze ....... ..... at No. —---------- ------ ... ........................ rect as shown on the ap plication for Disposal Works Construction Pv,"V't No____ ---- ----- ated__ : _ - ------------- 0 d of a], 40 DATE.------ 7: qf ---------------------------------------- FORM 1255 H0813S & WARREN. INC.. PUBLISHERS ' � #e .�° � ,� �� _..__._.�.�.,,�,,,,�m..�....._,.,.._..�.,_.�.,.. f .....�.._....__._.. ���4�� jj �`'� f �` f � Jf/F \ �% � i r .-.. l � ! '\ ,,iis _ k t � � � - i � 1 _ Fj ((( 4 «� �,t � � � 4 ""'^"^.. .��:.� '• �.,, r �� .� � t i - - . _ �.,� ��` . `�,, ;f TOWN OF BARNSTABLE LOCATIONSEWAGE # VILLAGE ASSESSOR'S MAP & LOT \g b ,�G� INSTALLER'S NAME & PHONE NO.�� d� � Ce� �\• \' SEPTIC TANK CAPACITY •7 o O LEACHING FACILITY:(type (size) 1000 oyd .Q, NO. OF BEDROOMS PRIVATE WELL OR BLI�WATE �► BUILDER OR OWNER C) DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: y IL L/ 7 VARIANCE GRANTED: Yes No !/ -- LC , ;i N o� .q \r -� .F I V r, AsBuilt Page 1 of 1 LOCg,T10 SEWO,C,E PERMIT M It�lSTQLLERS I.I�tJIE � ADDRESS � — 5UILOER 5 Q&MF— ADDRESS DATE PERVAIT DATE COKAPLIQ,thICE ISSUED ; 7y c6�c i a it L {J http://issgl2/intranet/propdata/prebuilt.aspx?mappar=190204&seq=1 2/10/2016