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HomeMy WebLinkAbout0140 ROLLING HITCH ROAD - Health 140 Rolling Hitch Road +' Centerville CP A = 192 094 sill UPC 12534 No.2� 53LOR HASTINGS,MN i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered compu r. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System kdividual Components Location Address or L t No. T. Q�[� Owner's Name,Address,and Tel.No. 6X/ap''�r�'CIf cei fv l 7 Assessors ap/P ce Insta er's Name ddress,'and Tel.No. +?7 •3 �'1 Designer's Name,Address,and Tel.No. oth A� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Of Nature of Repairs or Alterations(Answer when applicable) do q,f !7V Z it—, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. e Date l0 7 ?/Ilk Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued F Na THE COMMONWEALTH OF MASSACHUSETTS Entered mcomp.t r: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplicatlon for Misposar &pstetn Construction Permit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or L t No. `� Owner's Name,Address,and Tel.No. Assessor' Ado RsoMllar''CC eiTClf C� / 7 p/Pdree to h yt ITV I f l� 0 P y Inr's Name ddress,and Tel.No. sU 7 7 6'3 Y Designer's Name,Address,and Tel.No. JUP i�a,rN 1 A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd i Plan Date r Number of sheets Revision Date ,j Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answer when applicable) O 77 4 p P -�- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. n /O , //0 e Date Application Approved Z Date r Application Disapproved by / / Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS he{ �^ BARNSTABLE,MASSACHUSETTS + e-e Certificate of Compliance THIS IS TO CERTIFY,that the On-s'te Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at O u / C 1, has been cons cte in ac with the provisions of Title 5 and the for Disposal System Construction Permit No 3r *-7fi& Installer Designer #bedrooms Approved design flow / / gpd The issuance oft 's pe it shall not be construed as a guarantee that the system wj l /�/ri/ designed. 4 Date )(� /I b Inspector j------- ------------ ---------- ----__ y - - No. `� Fee— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby gr t oust t( ) Q'Repair( ) W#gae( Aban ( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction 7m)t/co 1 t d within three years of the date of this permit. Date Approved by i AsBuilt Page 1 of 1 of -a3 TOWN OF BARNSTABLE LOCATION ��lQ LI.�JII�g SEWAGE 0 VILLAGE 1�� I ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 100 q LEACHING FACILITY:(tgpe) 4 (size) NO.OF BEDROOMS ✓PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLiPLIANCE ISSUED; VARIANCE GRANTFD: Yes Ng http://issgl2/intranet/propdata/prebuilt.aspx?mappar=192094&seq=1 10/7/2016 Commonwealth of Massachusetts / d/ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments CD ell 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is a required for every Centerville MA 02632 10/5/2016 page. Cityrrown State Zip Code Date of Inspection Gf m Inspection results must be submitted on this form. Inspection forms may not be altered in-any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Joseph M Martins use the return Name of Inspector key. Accu Sepcheck ray Company Name 17 Northside Dr Company Address few South Dennis MA 02660 Cityrrown State Zip Code 508-385-5891 S1 147 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 10/5/2016 spector's ignature IF Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 L� � f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): GARBAGE GRINDER NEEDS TO BE REMOVED. SANITARY TEE NEEDS TO BE REPLACED. THIN CRUSHED PIPE FRON SEPTIC TANK TO DBOX NEEDS TO BE REPLACED t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown 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 FIND (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: fK ❑ 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. CitylTown 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 Forth:Subsurface Sewage Disposal System•Page 6 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK, NO DISTRIBUTION BOX , 2 LEACH PITS IN SERIES. 2"D PIT IS 6'X9'W 3'STONE. Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 153 9 ( Y 9 (gP ))� Detail: 2015: 55,000 G 2014: 57,000 G HAS LAWN IRRIGATION Sump pump? ❑ Yes ® No Last date of occupancy: 10/5/2016 Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown 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: 7/17/15, 4/2/13,3/9/10,2007,2003,1999,'93,'90... PER BWWTF 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): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °wM s 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 40 YEARS. INSTALLED IN 1976 PER BARNSTABLE HEALTH DEPT. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: —2feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10feet Comments (on condition of joints, venting, evidence of leakage, etc.): OK NO LEAKS Septic Tank(locate on site plan): 1' Depth below grade: 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: APP 8.5 X 6 X 5' 1000 G Sludge depth: 7" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 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 27" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? CORETAKER Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): HAS PRECAST INLET TEE , HAS PRECAST OUTLET TEE IN DETERIORATED CONDITION. WAS REPLACED W A NEW PVC AND GAS BAFFLE. NO EVIDENCE OF LEAKAGE. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness -- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 140 Rolling Hitch Rd Centerville MA ., Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 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 Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. City/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.): NO DISTRIBUTION BOX PRESENT Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A *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 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): THERE ARE TWO LEACH PITS IN SERIES. THE FIRST LEACH PIT IS FULL WITH A SANITARY TEE. IT OVERFLOWS TO ANOTHER LEACH PIT THAT HAS 28" OF LIQUID IN IT WITH A HEAVY STAIN LINE 12"ABOVE. RECOMMEND PUMP THE 1ST LEACH PIT AT NEXT SEPTIC TANK PUMPING Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 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 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. Cityrrown 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 O 2- STftW P(� 3 B)­':� 37S =�{p�� ` g y 40. 31 J - t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 page. CitylTown State Zip Code Date of Inspection D. System. Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS QUAD You must describe how you established the high ground water elevation: SITE IS >=60'ASL. GRADE TO DEEPEST PIT BOTTOM IS 12.5'. BARNSTABLE GROUNDWATER CONTOUR IS 36' ON 6/1992. ADJUSTMENT FOR SDW252C FOR 6/92 IS 4.0'. SEPARATION MATH: 60-(12.5+36+4)=7.5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 140 Rolling Hitch Rd Centerville MA Property Address Tia and Mary lerardi 140 Rolling Hitch Rd tia.ierardi@gmail.com Owner Owner's Name information is required for every Centerville MA 02632 10/5/2016 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 SY a93o COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ASSJ PAq ESSO NO• l�'a- RSMAP CFCNo. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION / / Property Address: I YG a(6! jZ4. C.'e^46'vi 11t4 24J Z T a . Owner's Name: / /Q -ahL( �Q� Ter a Owner's Address: / ',� � w' C-0 a a d 3 z.. Date of Inspection: /S- cz Name of Inspector:(please print) ( Joseph M.Martins cry 00 > Company Name: Accu Sepcheck Mailing Address: 17 Northside Dr., S.Dennis,AIA 02660 ca Telephone Number: 508-385-5891 r M CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: Passes ✓Conditi.onaliy Passes r-V yt 6-t%v-Ws4- 6-4tAhv 'f Oova Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signatur 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 1.0,000 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,ifapplicable,and the approving authority. GC*-ti G,, ,W,, l e e,,i0F.S Notes and Comments: rer . e of cZ ) PUAA?141 l aeCv4AjjA P4PA G f\ , R-OTW 11 aC 6. >I-M ****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. Pagee 2 of.1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 140 Roiling Hitch Rd.,Centerville,MA Owner: leradi Date of Inspection: 6/5/2004 Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. System Passes: I/ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 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 scat s.If"not determined"please explain. The septic tank is metal and over 20 years old*or tic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltrati tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic as approved by the Board of Health. *A metal septic tankwill pass inspection if' ' structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y s old is available. ND explain: Observation of ge backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Boar f Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND plain: 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: l Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _ 140 Rolling Hitch Rd., Centerville,MA Ieradi Owner: 6/5/2004 Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation by the B ealth in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Healt rmines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a man which will protect public health,safety and the environment: — Cesspool or privy is m 50 feet of a surface water _ Cesspool or pri 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 a Zone I of a public water supply. The system has a septic tank and SAS and th is within 50 feet of a private water supply well. _ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Meth to determine distance "This system passes if ell water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile is compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crit are triggered.A copy of the analysis must be attached to this form. 3. Other: .Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 140 Rolling Hitch Rd.,Centerville,MA Ieradi Owner: 6/5/2004 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or`ho"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'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _✓Any portion of the SAS,cesspool or privy is below high ground water elevation. __,,/Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _✓Any portion of a cesspool or privy is within.a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet ofa private water supply well. _ _✓Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this foruLl (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to erect the failure. E. Large Systems: To be considered a large system the system must serve a facility with a de ' ow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following.- (The following criteria apply to large systems in addition to th teria above) yes no the system is within 400 feet of a surfa inking water supply the system is within 200 feet o tributary to a surface drinking water supply the system is located' nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone If of a publ' ter supply well If you have answ "yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Secti above the large system has failed.The owner or operator of any large system considered a significant t 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 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 140 Rolling Hitch Rd.,Centerville,MA. Owner: Ieradi Date of Inspection: 6/5/2004 Check k if the following have been done. You must indicate`des'or'no'as to each of the following: Yes No V'� Pumping information was provided by the owner,occupant,or Board of Health 4--- 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? _V Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition 711affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum'? _ r provided with information on the proper Was the facility owner(and occupants of different from owner)g o ded p p ' maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no At-"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(3)(b)j Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ]Property Address: 140 Rolling Hitch Rd.,Centerville,MA Owner: Ieradi Date of Inspection: 6/5/2004 FLOW CONDITIONS RESIDENTIAL Number ofbedrooms(design): !I' Number bedrooms(actual)- DESIGN flow based on 310 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: �,, �p Does residence have a garbage grinder(yes or no). 1 /�P��sAp4 io W Is laundry on a separate sewage system(yes pr no).Wp [if yes separate inspection required] Laundry system inspected(yes or no):h `' 2-43 /07 V&P Seasonal use: (yes or no):--Al 0 It Water meter readings,if available(last 2 years usage(gpd)): 24 -2� e0 Sump pump(yes or no): /+/� Last date of occupancy: r 4-�h f/y MS t�ID r 2- COMMERCIALlMUSTRIAL -J Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc).. Grease trap present(yes or no): Industrial waste holding (yes or no):_ Non-sanitary waste arged to the Title 5 system(yes or no):_ Water meter gs,if available: Lasj-dawlol occupancy/use.- OTHER(describe): GENERALTw GRMAT /N I Pumping Records Q 20D 3 � Q 9t '�?J ` o>9 7j�/l e2- /9 l Source of information: Was system pumped asp ofthe inspection(yes or no):— If yes,volume pumped:_ __gallon-How was quantity pumped determined? Reason for pumping: TW OF SYSTEM Septic tank,distribution box,soil absorption system(Z) Single cesspool T Overflow cesspool — Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alte mauve technology.Attach a copy of the current operation and maintenance contsaat(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: le -&xgvoait S Y LtlYll?it._ Were sewage odors detected when arriving at the site(yes or now Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Rolling Hitch Rd.,Centerville,MA Owner: Ieradi Date of Inspection: 6/5/2004 BUILDING SEWER(locate on site plan) Depth below grade: 2. _3 t V ain : Materials of construction:—cast iron 1_40 PVC other(axp� ) Distance from private water supply well or suction.line: Co ments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:r(locate on site plan) Depth below grade: 1 Material of.construction: �oncrete metal—fiberglass_polyethylene _other(explain)If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) y/l0 �� V �j� ? l Dimensions: Sludge depth: f r% Distance from top o sludge to bottom of outlet tee or baffle: a Scum thickness: Distance from top of scum to top of outlet tee or baffle. �� t Distance from bottom of scum to bottom of ouget tee or baffle:��! How were dimensions determined: Comments(on pumping recommen ons,inlet and outlet tee or'—ffldf condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, c.): V C G r (`t n r- f C n d ! VP�T`l-h c) $ism /tag a�Q . GREASE TRAP:'(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 baffle: Date of last pumping: Comments(on pumping recomm ons,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,e ' ce of leakage,etc.): Page g of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Rolling Hitch Rd.,Centerville,MA Owner: Ieradi Date of Inspection: 6/5/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglasspolyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gall y Alarm present(yes or no): Alarm level: At In working order(yes or no): Date of last pumpin Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, xN etc.): / a. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump ,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- Owner: 140 Rolling Hitch Rd.,Centerville,MA Date of Inspection: Ieradi 6/5/2004 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain.why: Type _� �O x{o � �t � P[7-'�ot�llLt-•, leaching pits,number: leaching chambers,number: t** 9 leaching galleries,number: /Z X 10.I! a�Q"� /•r f leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:__ innovativelalternative system Typeiname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition.of vegetation, etc.): l ctc1) QC A01d1AA I)MA- kL L.. t nvex i s 1,;0i. ®620( 3 12ecdw6z CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: At Depth—top of liquid to islet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwat ow(yes or no): Comments(note on 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,lev onding,condition of vegetation,etc.): . Page It of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 140 Rolling Hitch Rd,,Centerville,MA Date of Inspection: leradi 6/5/2004 SITE EXXM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 2. Y Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: jZ�hecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: ' You must describe how you established the high ground water elevation: 6lqA 2,s�z _ l • e Page 10 of.11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 140 Rolling Hitch Rd.,Centerville,MA Owner: Ieradi Date of Inspection: 6/512004 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. r O t 1 � z 8�-=- 37S 3 � 31 =�{©�s; V � 3L3 TOWN OF BARNSTABLE LOCATION /�-pD ��� SEWAGE # /e VILLAGE r v1f 6-"/uAe ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) �Q _ NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE 'COMPLIANCE ISSUED: VARIANCE GRANTED: Yes N� I 1 Y .,� � �� t � `C i L0CATI N EWAGE PERMIT NO. VILLAGE , INS A LER'S AM i ADDRESS OR OWNE DA E Pf* MIT 1 D DATE COMPLIANCE ISSUED � � c-, �' .��� Ca � '�� - . � --__ �. .� � � �• r NoPl�..... FEi&..... THE COMMONWEALTH OF MASSACHU!�ETTS BOARD OF HEALTH .... .... 'Ir. .........OF.............. ................................ Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Systein at: ow ddr Other Distribution box Dosing tank e 4 licabi U _hnswer en applicable --------------- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TILE A.-� 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` KV7 � Date Application Approved By 'X — ' ^ ' Date Application Disapproved for the following rxu sons:............................................................................................................... .......................................................... � Permit No Issued-----.................................................. Date A, No.......... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. . ......................OF......................... ---------------------------------------.......... Appliratiou for Uhipaaal Works Towitrurtion tirrutit 1: Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syst t .......... . ...................... s"s, ............ -------------------- ........ ............ ......... .. ........... . ...................................... . .......... ......... ....... W . ..... ................................. ................. 1%d OSSA .................I.. ..................7!�:........*.., ...& ...... Installer Address Type of Buildipg, Size Lot............................Sq. feet U Dwelling4fi!f No. of Bedrooms........................................---Expansion Attic Garbage Grinder ( ) Other—Type of Building ----------------_--------- No. of persons............................ SlTowers Cafeteria ( ) A4Other fixtures ........................................................................................-............................................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter------------_-- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by-------------------------------------------------------------------------- Date......................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... r3;4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................. P4 ........................................................................... .................. 0 Description of Soil....... .................................... ................. ----------------------------------------..................................... U ................................................................................................................................................................................I....................... -------------------------- ......................................... -------------------------------------------------- _------- i - --------------- U Nature of,&pairshtt Alterations�__AnswerA . . ... .......-------------­------------ ...................... V ben applicable--- ------- ----- ........... . . ............. .... . ................ ------------- ................ ... ........................................ ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal,,System in accordance with the provisions of T ITI-71, 5 of the State Sanitary Code— The undersigned further agrees not toplace the sysieffi�in 0 operation until a Certificate of Compliance has been,issuco by &he board of ieARIth. SAO Sned.... ...... ................. ........................ ................................ D te. ....................................... ........................................ Application Approved By.... X—,2- X �.. Date Application Disapproved for the following reasons:.......................................................................1........................................... ................................................................................................................................. ...................................................................... Date PermitNo........ *............................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS �Y, BOARD OK HEAL T ........... . ........OF.........A�40... ...X ... .............................. (Irdifiratr of Toutplitturr '0 THIS ;�ERI t the Individual Sewage Disposal Systerh\ onstructed aired C or Rep by .............................. .......... ......... K;aii -------- . . . ......... ... ------------- ........... K . .......... ---------a--------I-------------- has been insta ed in accordance with th&- 7�1 -- - ------ -------- provisions of T 5 s escrihed?in the --/of State Sanitary Code a d application for Disposal Works Construction Permit No.46 --- --------- dated....... ....... THE ISSUANCE,�OF THIS CERTIFICATE.SHALL NOT BE CONSTAUED AS�_,GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... ................................................................ Insp6ctor..,-, ------�- -�e�A_ 1111�— ------------- THE COMMONW,EAL:TH OF MASSACHUSETTS BOARD 0),F HEALTH ............ ............0 F......... .16.A4&... ............................................. N.......................... FEE........................ ion Vamit Per I sl hher boy n t e g;......... .... .. ........ --- ----- .......Z inli�u �e r---------------------- .......... -------- to ons or p )An Ind vidu4a� $ewak is ys C at 0.. . ... ..... .... .................... ....... .. .... ..... .. .... .... .... ............. ........ N ............. Str. as shown on the application for Disposal'Works �onstruction Permi ... ..... ted........ .... ...................... .......... ---- .. .. ....... ........ ----- ----------­-­ ... .................... Board of Health 'DATE................................. ............................... .............. FO RMI 12 5 5 HOBBS WARREN, INC., PUBLISHERS 'i Fims............................... THE COMMONWEALTH OF MASSACHUSETTS e./ : E®AR® F HEA _...... OF.. ................................................• ....................._... Appliration for Dispoiial Workii Tomitrurtion Vamit Application is hereby made for a Permit to Construct ( _ t epair ( ) an Individual Sewage Disposal l� System at `l -- -------------- ------1 62� �� '_----- .-- cat oi�.,Td;,,,ess or Lot No...............� .-...............-.---: - ----..... -...-....•..-- --.-••..--•-••------•• -•........--.-------•-------•-.----••••-•••-••---.---.--.-.---------•••-- wner Address W a ----------------- -----------------------........=---------------------------=--........-- ------------------------------------------------------------------ ------- --------------------- Installer Address Q Type of Building ��jj Size Lot_____ , ._Sq. feet Dwelling—No. of Bedrooms__________7___...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ...................................................... W Design Flow_______________ ____ ____________gallons per erson per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacit __ llons h................ bVidth__-__..__._... Dete ---------------- Depth_-..___.__.____. x Disposal Trench—No._.____ _ dt _____ ____________ T tal Le with _____ __ __ __ �Ftal eaching area....................sq. ft. Seepage Pit No_____�0 � __ is ete ,__ ___ ____.___ T _.____________. leaching are, sq. ft. Z Other Distribution osing tankPercolation Test R Performed by---------------------•-•••-• - a ------------------------------------------- Date--------------------------------------- a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______________________. 0 Description of Soil............... •-•••-••-•••••-•• •••.............. -•-•••••-- --------- --• --------------•---------.•--._._.._.__.._._.._:__...---•--•---••-----••------- V -- ----------------------------- --- - --------------------------/-•••• -----•••••••••---•••••••••-•-----•--------------------•----------••--•--•-----•------------••-----••••------. W UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------_----------------- ---------------------------------------------------------------------------------- . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanit ode—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha bee issued by the bo f healt Signe -- _-----'--••••••• .._..L_ ••t -------------------- Date Application Approved By-• - •••--y at Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------•- / Date Permit No........................................................ Issued-- - Date --------------------- --------------------------- --- ------- -- -------------' No. . t_. • F� .............................. THE COMMONWEALTH OF MASSACHUSETTS -� BOAR® K, / / Z . r .... F"F O :. .............. .. ,k.ppfilration for Rovoiiat C onat.rurvia'n Urrutit Application is hereby made for a Permit to Construct (,-,,. Repair ( ) an Individual Sewage Disposal System at: ------------------•-- -/ LG 1C•G�-!zG� "'' oration-Address or Lot No. .... •• -•••--•--------•-•-•-- -•--C ........ ---------- ---- ----------------------------------------------------•-------------------___-_- wn Address Instal ler•. Address Q Type of Building Size Lot.--___,l", (1_Sq. feet U Dwelling—No. of Bedrooms---_:______�....__.___. .Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ____________________________ No. of ei-sobs............................ Showers Cafeteria Pk Other g f------------------------- --------------------------------------------------- •-------------------------------------------- Design,Q Other fix yss ____.___--.. ,' W Flow.............. _______ _______________glons per person per day. Total daily flow-------------------------------------------- WSeptic Tank—Liquid capacit _ ____ _.. "-`to s n h................ \Width------------ Di a ter_-_.- _-...__. Depth.-..-______---. x Disposal Trench—No.___ _____ dt _____ ____________ T,,al Le mth- ____ __ __ _ leaching area__---_-.____-.-___._sq. ft. Seepage Pit No______________�_ �j�to ___' ___ ____ _ i> __.________ otal leaching area.....40)—sq. ft. Z Other Distribution bo � .osing tank ( ) a Percolation Test Results\ Performed bY---------------------------------------------•---------------------------- Date---------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit---________________. Depth to ground water----_-----________---.-. t=, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-__________________-.-. a, xDescription of Soil--------------- -- - - --- -- a U ;= -- - W , ------------------•----------------------------------------------------------------------------------- -----------------.------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable---------------------------------------________________________________________________________. ----------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanit y ode= The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha bee issued by the board of heal Signe .--- «� Application Approved By._ .fat / Dates ---- 3_. Application Disapproved for the following reasons: --------------------------- !, --------------- ............................ PermitNo.. =................................. Issued................................ ....................... Date THE COMMONWEALTH OF MASSACHUSETT /� " // '• ^ BOARD. OF HE/�LT ',` ...............OF...... ..................... ....:.....:..:.............. : ........ �>er#ifir�t��e of t�li�tatsp . �.. THIS IS TO T� the In ual S a e D•.posal System constructed ( Repaired ( ) by .--- Inst er at ----••---• ----•--- ----••------------•--• --- -- _._ ------ ;- .�C .__ ;; 01 .... --•------------------•--- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------------- dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED�S A�GUARANTEE THAT THE SYSTEM WI XL FUNCTION SATISFACTORY. DATE -_----•-_-_-------_--__ Inspector.------ -------------------------------------------------- T E COMMONWEALTH OF MASSACHUSETTS �, BOARD OF HEALTH ,l r ..........................O F.-...... No.... ...A.... ............... ...------ -.-...--------------------------.... FEE_ !Ae ROW� z = Permission is h eb granted----._..., - to Construct ( or 'ep 'r ( ) In ual Se age is sal System �. at No. '........�.. ----------- - ------ ------------------------------------------- as shown on the application for Disposal Works Construction Per Street'• _____________ __ __ at __w2 DATE------------------------------------------...................................... th FORM 1255 HOBBS &.WARREN. INC.. PUBLISHERS