Loading...
HomeMy WebLinkAbout0190 ROLLING HITCH ROAD - Health 190 Rolling Hitch Road Centerville A= 192-098 SMEAD No.2-153LOR UPC 12SU am&".-* - Made in USA W uwjmvm tIQW SFI Immsmommaymm s� wWs�woowu,,a„ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for CENTERVILLE MA 02632 DECEMBER 13,2012 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. ImpoWhen filling A. General Information When filling out forms on the computer,use 1: Inspector: U only the tab key to move your MARK L WHITE cursor-do not Name of Inspector use the return key. NEIGHBORHOOD WASTE'WATER Company Name 350 RT 28 Company Address WEST YARMOUTH MA 02673 City/Town State --.--- Zip Code 508-775-2820 S113381 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: �NtOF Mgg���i�� Passes ❑ Conditionally Passes ❑ Faile,�.` • s9�;''��� g: MARK ;yc= ❑ Needs Further Evaluation by the Local Approving Authority _o WHITE _ `'A•: No.S13381 '* TI FRF\� .DEC ER 13, 2012 ,, �F1IF•• . ....••G� `��. 11i111ii S INS?" `\����� 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 bf 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. lystlt5ins•11/10 Title 5 Official I c n Form:Subsurfa�Sage is m ge 1 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form k e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 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: ❑x 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: 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken.pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ' 0 obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): El 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): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 20 • Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityrrown State Zip Code Date of Inspection C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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 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. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 20 • Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T• 190 ROLLING HITCH RD _ Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 City/Town . State Zip Code Date of Inspection 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 El Z clogged SAS or cesspool El 0 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 ❑ ❑x Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow B. Certification (cont.) Yes No ❑ ❑x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name -d for require every page. CENTERVILLE MA 02632 DECEMBER 13,2012 City/Town State Zip Code Date of Inspection ❑ ❑x 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.] ❑ ❑x The system is'a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply , ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El Elthe 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. C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑x . ❑. Has the system received normal flows in the previous two week period? t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 20 Commonwealth of Massachusetts 16 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityrrown State Zip Code Date of Inspection ❑ ❑x Have large volumes of water been introduced to the system recently or as part of this inspection? ❑x ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A)N/A 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑x ❑ Was the site inspected for signs of break out? ❑x ❑ Were all system components, excluding the SAS, located on site? ❑x ❑ 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 X El 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: ❑x ❑ Existing information. For example, a plan at the Board of Health. ❑x Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D.. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of 330 bedrooms): D. System Information t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 20 Commonwealth of Massachusetts Title 5 Official In Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityrrown State Zip Code Date of Inspection Description: Number of current residents: 2 x❑ ❑ Does residence have a garbage grinder? YesNo Is laundry on a separate sewage system? If yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? 0 Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2010-54,000 GALLONS 2011-59,000 GALLONS t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityrrown State Zip Code Date of Inspection Sump pump? ❑x Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 3.10 CM 15.203): . canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes El No Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: B.O.H. Was system pumped as part of the inspection? ❑ Yes ❑x No If yes, volume pumped: gallons t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page, CENTERVILLE MA 02632 DECEMBER 13,2012 City/Town State Zip Code Date of Inspection How was quantity pumped determined? Reason for pumping: Type of System: ❑x Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and - maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 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 ❑x No Building Sewer(locate on site plan): Depth below grade: 30 INCHES feet Material of construction: ❑cast iron ❑x 40 PVC ❑other (explain): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 20 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 City5own State Zip Code Date of Inspection Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): INSPECTED MAIN LINE WITH SEWER CAMERA, LINE IS CLEAR Septic Tank (locate on site plan): Depth below grade 20 INCHES feet Material of construction: ❑x 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 ❑ Yes ❑ No certificate) Dimensions: Sludge depth: 3„ D. System Information (cont.) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityrrown State Zip Code Date of Inspection Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 4 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) INLET AND OUTLET TEES IN PLACE, NO SIGNS OF LEAKAGE Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T �. 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityfrown State Zip Code Date of Inspection Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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 grader 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.): I t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 City[iown State Zip Code Date of Inspection *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert AT 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, etc.): DISTRIBUTION BOX IS IN GOOD SHAPE 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name reuired for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityrrown State Zip Code Date of Inspection Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: D. System Information (cont.) Type leaching pits number: 6X6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ Teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 20 Commonwealth of Massachusetts r Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name d for reuire every page. CENTERVILLE MA 02632 DECEMBER 13,2012 Cityrrown State Zip Code Date of Inspection ❑ 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.) SOIL IS DRY, NO SIGNS OF HYDRAULIC FAILURE, THERE IS 30 FROM INLET TO LEACH PIT TO LIQUID LEVEL 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 D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 20 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments X. 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 City/Town State Zip Code Date of Inspection 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 20 AL Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name requited for every page. CENTERVILLE MA ' 02632 DECEMBER 13,2012 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 ❑x drawing attached separately t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 18 of 20 f Commonwealth of Massachusetts Pi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 City,rrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope Surface water ❑x Check cellar ❑x Shallow wells Estimated depth to high ground water: 12 feet feet r Please indicate all methods used to determine the high ground water elevation: ❑x Obtained from system design plans on record If,checked, date of design plan reviewed: 5/30/79 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: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 ROLLING HITCH RD Property Address Owner KATHLEEN CHANE information is Owner's Name required for every page. CENTERVILLE MA 02632 DECEMBER 13,2012 City/Town State Zip Code Date of Inspection You must describe how you established the high ground water elevation: PLANS DATED 5/30/79 STATES NO GROUNDWATER FOUND AT 12 FEET Before filing this Inspection Report, please see Report Completeness Checklist on next page, E. Report Completeness Checklist ❑x Inspection Summary: A, B, C, D,.or E checked y ❑x . Inspection Summary D (System Failure Criteria Applicable to All Systems) completed F System Information— Estimated depth to high groundwater ❑x Sketch of Sewage Disposal.System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 20 of 20 of 4 4 http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mapparI92098&seq=1 12/26/2 AsBuilt Page 1 of 1 LOCATION SEWAGE PERMIT NO. VILLA.GE INSTALLER'S NAME & ADDRESS Z! t.-A C e,,;/ /,yIlle, e UI'LDE R OR OWNER ,.1 M 4 A/ K�e eailtlle, DATE PERMIT ISSUED DATE COMPLIANCE ISSUEDd—O Id --�� �7 � f _ y o w C44 c� z, http://issgl2/intranet/propdata/prebuilt.aspx?mappar=192098&seq=1 12/3/2012 LOCATION SEWAGE PERMIT NO. d✓ 7z VILLAGE I N S T A LLER'S NAME & ADDRESS JdIne f)o1/ -W4y E B U I L D E R OR OWNER � e DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 0 (v (;4Q �C f f Z� ' 2 / No................... Fic$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -. 0.CAJ M.---.... .OF......... I Q ApplirFation, for Uhipogal 10orkii Tnnitrnrtion rantit Application is hereby made for a Permit to Construct (d',,*or Repair ( ) an Individual Sewage Disposal System at: ..---...----•----...4—V-.......... ::�t------------------------------------------ 5� .. !4 Y........................... ur �°t NO. Owner Address Lam® A-if Install Address d� Type of Building Size Lot.J1 i O_o .......Sq. feet r,.• a Dwelling—No. of Bedrooms____________________________________________Expansion Attic (Nv) Garbage Grinder (iV� °a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ). d Other fixtures ................................. _....- - --•_.-•--------------------------- W Design Flow........ZZ.a........................gallons per per day. Total daily flow.._..........3_3..4?................gallons. WSeptic Tank—Liquid capacityl.O.&A..gallons Length.6...!9�". Width._$ 'Z,�."' Diameter................ Depth.. ��'1_.`d. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. P P s g ...sq. ft. Seepage Pit No._.../_..._...... iameter____.�.._._..... Depth below inlet..._��____ ________ Total leaching area. Z Other Distribution box (Y) Dosing tank ( ) _ aPercolation Test Results Performed by.M.0-A14AV...A.r.6-4,0�0RV).....k_.a.r.... Date..... Test Pit No. 1.4:4.......minutes per inch Depth of Test Pit.....�.2n........ Depth to ground water.AjP v.ff....... Test Pit No. 2..:�=-_...minutes per inch Depth of Test Pit.... .......... Depth to ground water.AJDe1l.e....... •-•••-••••••----------------•--••••••••••-•••••••-•••••-••-.......•-•..........................----•.................................................... O Description of Soil---.. A•Zhl ..._.... dl a._S�sr _.�_.`_%//U .. ✓9i+c _._.. U ........ 1R.•••........��._ 1.. .... - •--•--•---•••.............•-._........._--------_.........._..---- ------------------------------------------------------------------•--•------•-----------------•-•-------------•----------------------••-••-•-------•---•••-•-•-•---•-••---............-•-•-••-----_.... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •• •• ----•-•-•-------•--------•-•---•-------•-•••-•••--••-•--.....----••--•••..................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT:.^. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig nEd------ .... ---•----•----------•-----•-•-----------•-•---------•--------------•- ��D,te Application Approved By.....::__ �" �en --.6�I/•!�.- --•------...---•-- -•�---•-------Date �---- Application Disapproved for the following reasons:................................................................................................................ --•-•........................••••••--••-•--•••-••-•••-••-•-••--•--••••••••••---••.....---••••••-••-•-•-----.._...._._.............••-----•-•----•••-•-•_•------•---•J -••--.•-----• ...••........__..... W Date PermitNo......................................................... Issued_..... .(-r...... ........!.--•-• --------- Date L oo No.............M...... , Fx$...., :. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'T C�:�,c�-A)............OF.........B.�.l�.i�.AJ..�-74-1 :G•.,t ...........:.................. .gyp iration for Dispogal Works Tonutrttrtion Vrrmit " . Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal :., System at:"-`- N.:....�,..,F% 7.'4-*R-k,14Z-4F------------------4.0- ------... ...............--- Location-Address .... 4, e , ,q.-. r wner .......................... � .! r.L..o.t. No .... ........aU Address . .d . i .......... nta Address T e of Building Size Lot..1:SD- '5K.......Sq. feet .� Dwelling—No. of Bedrooms .. ..................... ............Expansion Attic:}(Nip) Garbage Grinder (kd aOther—Type of Building ............................ No. of persons........__................. Showers ( ) — Cafeteria ( ) Other fixtures y� --------------------- W Design Flow......_.lz!' ................. gallons per, Pe dqy Total daily flow------. ...............melons. W Septic Tank—Liquid capacity/42da.gallons Length & X ' Widtth._ ��Diameter___._ _,_ llepth__ *#�'L x Disposal Trench '�To..................... Width _............._._ Total Length ,..._... Total leaching area sq. ft. Seepage Pit No...._Z.- _..... iameter . ... ..... Depth below inlet ,: Total leaching area. ..f ...sq. ft. "N* Z Other Distribution box ( ,Dosing tank aPercolation Test Results Performed bj RjJr`QA K. I' :. l r Q,Czr?....k.S�e.... Date...... ..� Test Pit No. 1.,c'-k......minutes per inA,A Depth of: Test Pit..... ='.... Depth to ground water-AACN.0...,__. (i Test Pit No. 2..4.fir.--•minutes per inch Depth o TAt Pit e�f Depth to ground water.l lobe...... a, ..: �: :.. ........... O Description of Soil __ .� :" � .s-. / ' �►;"� ` A .� � Qxu - ---•-------------------------------------------------------------------•-- ---- •-• -----------------------------------..........-----------....----•----•-.-_... U Nature of Repairs or Alterations—Answer when,apicable ._ .............................................................................. Agreement: t The undersigned agrees to install the aforedescribed'r Individual Sewage Disposal System in accordance with m=,. f '"" the provisions of LI LE, 5 of the State Sanitary Code`— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si ed. ... .-•_.. _......-----•-•-•--••---•-•-•••---•--•-- Date Application Approved By......_ . . .—Jelzl,�,;�1;1(4,w— •------------- '-���� 'Dae'� Application Disapproved for the following reasons: -•-•---......---•-•-----.....••-•-----••----•-•-----•----•----•••••--•-•._.....� •�. •--•----------------------------------------•---•-------------•--•-----•---------.........................--------•-----------------•------•------------------------------------••---------•••--------•-- Date PermitNo................................••-----•......-•------_. Issued-...........................= ....................... Date THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH ?..!u..........4: OF..... / :A+,. .r-........................ (Inrtifirate of Tomplianre HIS IS O CER Y, 1 ,thhe�Ipdividual Sewage Disposal System constructed (1 ) or Repaired ( ) by - .... .. . I !! -----------nst---aller---------------------........ ----------------------------------• . -------... -------- # at.....t'`: ......... .?`I-------�---,6.1...... _`_ '' ' `-f -E�t ----------------------- has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit 1N'6..._ `f ................ dated__ ._.;,$. -_�._ g ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... . .--. .... Inspector.................................................................................... :.. THE COMMONWEALTH OF MASSACHUSETTS 01-1 BOARD OF HEALTH 1 (f "' 0..... N........O F..........% - �'Sr:P.lf .! .� fir. .................... io tt1 Nor it nr#ion Orprutit Permission is _ereby grantef" s• J ••-•-•----...... to Construct (." or Repair an Individual Sewage Disposal stem at No.......,P.... ..--•----•--. Q !i! ........ ' .............................. /f- '',�� t!...._ t � Street PP .i as shown on the application for Disposal ti'l�'orks Construct on Permit No__ _________________ Dated ..__._ .. __......... � . . w DATE------------------- --------------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ~;`•., 10 TEST 1-1 JONE /4 ClR-RA PAUL. .ri � 'Y SMS PE T toy pq SAW 0 ' r GARAGE vi E L k13 OaZ. t NO GJA TER' �F:CGONT,E-C C O Ln ® ul LoT 90.0 kn .� TOWN !-,JATER AVAILAM4..E �r in o d p rL V ci 7:) Cl- n }' 0 o /3 u/LZ7/nrG S ETL3AC/c �E�U/,��MF.�/T5 SCQ L E. / ._ ,30 -IOOAl T A9_ Si-DE /0 1-02 ATE p2�p0 SED _� BE_D200MS SE P T/C 5 Y5 TEM CONS T2 UC T/ON SHA 4-Z- GONF02M TO MASS . DES/GAJ ,7L 0W. Qr GALS 17.A Y E NVJAe OA//y.C-n/T�L COOS T/7-L L -Y L G-,4 c,4 2.4 TE 2 oP0S�'D iEA'IS�J "- -/- 7.7 6A1?NS TABEE .eEQU/,eG-� Z-EACC I,,,4Z 4M32 +6���/G�/ A/EAILTN TZ��C.JLA7"/ONS p' TOP OF , ,o2O�OS G E�) Z-.E 00 2 OF T�E,4 S'7-OA1E a 5 M A n/N O L,-- Co✓E/z TO &)c TE n/D TO ,oE.�✓/O US Co✓E./2 t / Wl TN/A/ ./' OF G_/A//S/q E[7 6/z,a D� TO ,a2E✓E,l/T/A/F/LT2AT/A/"O _ D/S T. (� / T O/L/E / coy— 2% G,PADE q"Casr 30X i� Z/"w,tDe aciEe 6"M i Pj —� 3•,Min/ 4., D/A N/ATFeZ / `—� MTV/TG�M —FL Ow L �vE �- ,y, T�G,�r 4 D/a. ���� /O LGq c�/ C� C N o,TGf/ - - , /4r. /FOOT /O"M/N / "2" ^'1/1v /=P/rcf, �, D/� /%2 D/A. Y 1QLJ�/ M,N ,yS /4 '/Poor '- �Q �WA5 HEc7 / - /NvE�Z r C , 5,5 TO A/E —_— GAL L L O /A/✓6.2T /A/VE2T C,ca PAC/ TY A2"0Un/O Tf1 �/e I / ELEV. I (-I1/A T/G//T� N / VIC—Zr � � �! Piro/ //v V E A-r N - C�ArCBA6E GcINDE 2 L oCQ 7-/0ti , rat " 11 {SF s SEDT/G TAN.<'t 0/STA;2 4 L5 7-/ON BOX IN I�L19 �Q � PAE--�02-�-- ---'� 'P'' �ny\� �SOUTLETS) An./D L,r--AG,d,-//,vG 'j-/T `�4; �,,; `� ONC2ETE ST2E•VGT7� 0000 __ _ U _ \ c ; � TEFL ,. 20000 A/4. 4.C�i�st+��`r � �"" '7' ,C•? k �� aR UI`/v'r t %�y' /�/�T TO Z3� L 7C,4 ✓E,Z 57'jTE 5 A/— 20 .1 CERTIFY THE BUILDINCr �.'�CUG_i�l t<,V. %='��= t� ��-S/v�1 Z-04CVA10 ./Z:� :✓SE1>. TN/S PLAN /S PROPIOgS,�:}:`�J'-3 ON -rIV �; ,�E'��., ,� ,, REVISED TUNE Ia/l9 79 G R DLJ N D AS SA/,')L--)IV AND D l { L D L.�) " � �a h•.iRrse �3"` -- �___. r P .Y t1/!;f� 7" 13C.'!L. L?i:1�0 S TU'/J r o),r iU(c') of �� ` r -- --- ---- -----'- _ f .. GAR r,r S`'',A 13 L/± ��'! �_ �.�y�,'� fla TE /-1E<iL7�/ AC:E3 T