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HomeMy WebLinkAbout0036 SEAN'S CIRCLE - Health 36 Sean's Circle, Centerville UPC 12534 No.2153_R Ate, "l k$TlNO• ON o� M S M : Commonwealth of Massachusetts Title 5 Official Inspection Form f _ i� Subsurface Sewage Disposal System Form - Not foF Voluntary Assessments op=hy Address a', p Owner 0-mer's -forrator:is Na- Q reauired for every ?�:eO ` � page. vi ti;i ovm 3 r.e p Ja:e of Inspqor 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. Irnpor=t:w ian A. Inspector Information filling out forms a V" / on the ccmouter, /w/ use only'he tab Key tc move your Name of i pectcr �� cursor-do not use the return ) �� key. Company Nar.re O X m i Company Addr=ems 0 ) /' 1 J p[-to z/, own Q Jtat� Zip Code City— ,}�o, eieoho \u-ber _cease Number B. Certification certify hat: l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); i have personaily inscected the sewage disposal system at the property address listed above:the information reported beiew is true,accurate and complete as of the time of my inspection: and the inspection was per•ormeu based or:my training and experience in the proper function: and maintenanc on-site sewage disposal systems.After conducting this inspection i have determined that the sys` , 1_ Passe.., 2. i Condfuonaiiy :Passes 3. Needs =unther Evaivatior, dy:he `_coal Approving ,Autnorty ".. _1 Fails S d-C !nSC C-Lc� .s ignazure ':Jaffe The syster inspector s;,a subr r a ocp of u,s inspection repo-to the Approving.authority(Board n=Heal'^, cr DC�)within 3C pays o`. ccrnpieunc t :is inspection:. if the system has a design flow of o,OCC nod or create-.th,e inspector anc_ne system owner,stall submit the report to the appropriate regional office of the DCr.The or;cinai forr- should be sent to the system owner and copies sent to the buyer, if appiicabie, and the approving author y. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. -._e❑,...,.e•rspe==r.?c.—.S.csc=zx 3ewzge sxsa systarn-Rage a is Commonwealth of Massachusetts Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Sea 45 ctY- Property ,Address �GN �V Owner Owners Name information is 0�required for every e� jI /'? { � O�0 0 page. CitylTown State Zip Code Date off speyn C. Inspection Summary Inspection Summary: Complete 1, 21 3, or 5 and all of 4 and 6. 1) System P 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: 2 System Conditional) Passes: Y Y ❑ 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 , "noll or"not determined" (Y, N, ND) for the following statements. If"not determined,- please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ N ❑ ND (Explain below): t5insp.tloc rev.7f2612018 71de 5 ofSQ&inspecac =orm:SLOsu'fface Sewage 7sposa system•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments See,-Yu G �- Property Address Owner - � Owners Name / /� �_ J information is eo eevc //t c 7d 57 c0 required for every p� page. Cityrown State Zip Code Date of inspectio C. Inspection Summary (cons.) Z) System Conditionally Passes (coat.): ❑ Pump Chamber pumpsialarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced —I Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is ieveied or replaced Y ❑! N ❑ NO (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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health; safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doe•rev.7/25f2018 -:5e 5(?(ficai:cspec:cn=o:—:Suns :lace Sewage Disposal System•Page 3 e`',8 Commonwealth of Massachusetts Title 5 Official Inspection Form �y Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments i c KS G!r Property Address awl✓ Owner Owner's Name information is _�1 / �.�`le- �� 1 0: �o � �O�'d 0 (,/e -�f�/ required for every page. City,7own State Zip Code Date of Inspe tion C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: **This system passes if the well water analysis; performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections. Yes No ❑ ackup 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 V due to an overloaded or clogged SAS or cesspool -;y ;5p e;� aj!nsoe,jc 1=OT'::suosu�Lce sewage Disposal System•Page<of t 8 t5insp.Coc.rev.726/201 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J k0z'-w) Property Address, �+ Owner Owner's Name information is 2N'��1�y�Ae required for every — '��W✓ page. City/Town State Zip Code Date of insp ction C. Inspection Summary (cons.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded — or clogged SAS or cesspool L_I Liquid depth in cesspool is less than 6" below invert or available volume is less u than ' day flow � Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: LJ 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. 2/1 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. i 1I Any portion of a cesspool or privy is within 50 feet of a private water supply well. An portion of a cesspool or privy is less than 100 feet but greater than 50 feet �] V y p P P Y 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 a d chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- lll��� 10,000 gpd. r The system fails. 1 have determined that one or more of the above failure J L_ 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 riecessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either'yes': or"no-to each of the following, in addition to the questions in Section C.4. Yes No (] i the system is within 400 feet of a surface drinking water supply �I 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 11 of a public water supply well Ci9e 5 OfBds;inspection Fore:suosu,-ace Sevrage oisoosal system-Page 5 of 18 t5insp.00c-2v.7f2e201 e Commonwealth of Massachusetts I- % Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Property Address r �i f/1 Owner owner's Name f�h e 4 information is ��/I required for every / o^m tate Zip Code Date of Inspe tonpage. 7i C. Inspection Summary (cont.) If you have answered"yes'to any question in Section C.5 the system is considered a significant threat, or answered "yes'to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes o xo , umping information was provided by the owner, occupant, or Board of Health ere any of the system components pumped out in the previous two weeks? as 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)] TIJe 5 `dzt inspec�ion?oc'.suosurface sewage Disposai system•?age 5 of?d t5insp.doc•rev.7262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis osal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name n information is required for everyr-ep., V7e,,-V-/ oco a �` page. City[Town State Zip Code Date of Inspection D. System Information .1. Residential Flow Conditions: Number of bedrooms (design): (.(y 'dumber of bedrooms (actual). DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: `aoo 1-4 Number of current residents.- Does residence have a garbage grinder? ❑ Yes 2- No Does residence have a water treatment unit? ❑ Yes o If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 2� No information in this report.) Laundry system inspected? ❑ Yeses Seasonal use? ❑ •Yes [ I o Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ��Yes No Last date of occupancy: Date ;Sinsp.doc-rev.726/2018 -iue 5 C�f"dal:ns;:ecnor=crm.Sucsusace Sewage Dispcsal System•Page 7 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form rr Subsurface Sewaje Disposal System F -Not for Voluntary Assessments �I e A.! ' G�r Property Address Owner Owner's Name _ information is / ? required for every Ce$4"Y1 L�1 z O page. City/Town State Zip Code Date of Inspec on D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, i aavailable: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as par of the inspection? ❑ Yes �' ��No If yes, volume pumped: — gallons How was quantity pumped determined? Reason for pumping: t5insp.tloc•rev.7/262018 -ite 5 07fi0a,:nsce=O,n=om.SLCS�aGe Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Property Address 41, �Gt N , Owner Owners Name �lil / `' b� Information is l/ /��,✓�_i � O prfl required for every �p State Zip Code Date of In echo page. City/Town D. System Information (cont.) 4. Type of Sy Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all comp ents: date installed (if known) and source of�' formati al 99 � Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): lu8 .3 Gai ir.Specilcn'0�..SUL ace sewage Disposai system Page 9 of 18 tSinsP tloc•rev.7/25/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Rio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2,c Se-dz 145 C (r- Property Address / I I QN• V Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Ins ctio D. System Information (cost.) 6. Septic Tank (locate on site plan): Depth below grade: feet (/ Material onstruction: 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: >C Sludge depth: �a Distance from top of sludge to bottom of outlet tee or baffle J Scum thickness let ti 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? 07 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.)-. v'► j h C7 /!O� aN 4,1 art 6&1 /TTo✓1 AV J__,ea 4�r t5ir,sp.doc•rev.7/261'2018 iae 5 MQa;inspection Form.Suosurace Sewage Disposal System•?age 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments c��-�vt,S l�r lam' Property Address / �GNh/ Owner Owner's Name information is / C �1 /� ' G�'� o�C7 required for every page. City/town State Zip Code Date of Inspectio D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete =1 metal 71 iberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day T¢le 5 pt5aa:insc��on Fom+:Subsurface Sewage-Disposal system•Page 11 of 18 t5insp.tloC•rev.7/26,2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /mil'a N Owner Owner's Name information is G N ao 02 required for every State Zip Code Date of Inspe ion page. City/Town D. System Information (cons.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). 1s copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): n� 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, etc.): o X Le{ ?nle=C; cti.nspa'=ion Foy Suosui.ace Sewage Disposal System•?age 12 0(18 t5insp.00c•rev.7252018 Commonwealth of Massachusetts s. Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments seQ44 it Property Address A'N -F:/_1 Owner Owner's Name V✓� �, o AL d� information is Le, ,� 020 required for every page. Cityr own State Zip Code Date of Insp tion D. System Information (cant.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan: excavation not required): If SAS not located, explain why: Type � Zr- uleaching pits ❑ leaching chambers number: !❑ leaching gaileres number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions. — ❑ overflow cesspool number: ❑ innovativeiaiternative system Type/name of technology: - e 5�5ca::rspesJor.=cm:Suos'm`c sewage Disposal system•?age 13 of 78 ri 5insp.doc•rev.7125/2018 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspe lion D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ;0V1 jj/�j,0,7 jr 9 rkej:�� 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -me 5 a"::cai mspecuon Form.SIX—face Sewage D'sPosai System•?age 14 of 18 !smsp.doc•rev.7/2 6120 1 8 Commonwealth of Massachusetts p Title. 5 Official Inspection Form IM ;' Subsurface Sewage Dis osat System Form - Not for Voluntary Assessments Property Address �r`a yr Owner Owners Name / A4 ��/ information is �eH /- �6 f0 ,� c;o p?� required for every page. City/Town State Zip Code Date of Insp ction D. System Information (cons.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 'roe 5 C`fiaa nsoeceon=onn.swsur`ace sewage osposa system•?age 15 of 1a t5msp.00c•rev."126'2018 Commonwealth of Massachusetts - lg Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner 1 G3 VP Name a�3� information is 0 mobt pq required for every ,� page. Cityrrown State Zip Code Date of insp 2tIon D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view f the sewage disposal system, including ties to at least two permanent reference landmarks or enchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buildi . Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately i i / - /1 I C /oo n j Fyn 1 6-e,/low 7- N 1 Mee _ l i I t5insp.doc•rev.7/26/2018 -it1e 5 `aai!rspecacn=em:Subscrtace sewage Disposal system•Page 15 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � Owner Owners Name information i e required for every page. Cityl I own State Zip Code Date of I pecti,36 D. System Information (cont.) 15. Site Exam: I_) Check Slope Surface water ❑ Check cellar D Shallow weils �-- "A Estimated depth to high round water: / p g g feet Please indicate all methods used to determine the high ground water eievation: Obtained from system design plans on record If checked, date of design plan reviewed: pate Observed site (abutting property/observation hole within 150 feet of SAS) I j Checked with locai Board o"Health - explain: Checked with locai excavators; installers- (attach documentation) Accessed USGS database-explain.- You must describe ho ou s blished the high ro end way ter ill d 0 .�2 e AQ Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5insp.tlOc rev.7262018 -Ge 5�--=a!,nsx=on Ferro:suosu'ace sewage Dpo issal system•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 42. YV Owner Owner's Name ��i -1 information is H V! 0�.G ?d required for every page. City/-Town State Zip Code Date of Inspect] n E. Report Completeness Checklist Com=�In icable sections of this form inclusive of: or Information: Complete all fields in this section. B. C .fication: Signed & Dated and 1, 2, 3, or checked C. Inspection Summary: 1, 2, 3, o completed as appropriate 4 ilure Criteria) and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included ':ue 5�`aa!nsxccn=a—::Suosurtacz sewage Disposai system•?aye tb of 18 t5insp.doc.rev.7126,20`18 Conunonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection John Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector IF P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor l l ARGEO PAUL CELLUCCI �,f0i� U.Governor ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ORT A p� CERTIFICATION RFCEl�vF� NO Property Address: 36 Seam Circle Centerville Address of Owner: 1997 Date of Inspection: 11/7197 (If different) TOWNOFS Name of Inspector: John Graci Charley Pires c HFA(TN, TABCE I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) co Company Name,Address and Telephone Number: a9 � CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria defined In Title V _ Conditionally Pas es code310CMR16.303.My findings are of how the system Is performing at the time of the Inspection.My Inspection does _ Needs Furt r aluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Falls septic system and any of Re components useful life. Inspector's Signature: Date: 11110197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection-,or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by.the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 seans Circle Centerville Owner: CharleyPires Date of Inspection:ttn197 _ Sewage backup or breakout or hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist whic h require further evaluation by the Board of Health In order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PRO SAFETY AND THE ENVIRONMENT: PROTECT THE PUBLIC HEALTH AND Cesspool or privy is with'P vY m 50 feet of a su rface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well; unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or 3)Other less than 5 ppm. Method usedto determine distance (approximation not valid) D) SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. — SAS is in hydraulic failure. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 Seans Circle Centerville Owner: Charley Pires Date of Inspection:W7f97 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No , the system is within 400 feet of a surface drinking water supply 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (rerlsed 0412P97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 36 seans Circle Centerville Owner: Charley Pires Date of Inspection:1117I97 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _x_ _ Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with NIA. x _ The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. ' x All system components, excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)(15.302(3)(b)] (revised 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 36 Seans Circle Centerville Owner: Charley Pires Date of Inspection:11n197 FLOW CONDITIONS RESIDENTIAL: Design flow: 3w g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: e Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rea Sump Pump(yes or no): rao Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: ma Design flow:o gallons/day Grease trap present: (yes or no) Nc Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no)­No Water meter readings,if available: rnra Last date of occupancy: nla OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last year. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping: Maintenance TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes. attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source Information: ONglnal system 15 years with new pit installed opproslmatety li years ego. Sewage odors detected when arriving at the site: (yes or no) No (reylsed 04R7197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Seans Circle Centerville Owner: Charley Pires Date of Inspection:W7197 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'6"H5'7^w4'10" Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness:4" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 14" How dimensions were determined: Measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:nh Distance from lop of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumpingrila Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) nfa BUILDING SEWER: (Locate on site plan) Depth below grade:_x'6" Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line!0— Diameter: 4"_ Qi1mments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04127197) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Seans Circle Centerville Owner: Charley Pires Date of Inspection:11f7f97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal___FRP_Polyethylene—other(explain) Dimensions: rda . Capacity: rJa gallons Design flow: rda gallons/day Alarm level:_nfa Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nta DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) The D-box is structurally sound. y PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)to Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nfa (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 36 Seans Circle Centerville Owner: Charley Pires Date of Inspection:11I7197 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits, number: 2-11,000ganonleachpn leaching chambers, number:rue leaching galleries,number: Na leaching trenches,number,length: rda leaching fields. number, dimensions nla overflow cesspool, number:nla Alternate system: nra Name of Technology:_rda Comments:(note condition of soil,signs of lydraulic failure,level of ponding,condition of vegetation, etc.) The leach pits are structurally sound and functioning property.The new pit wait 3!4 full. CESSPOOLS:_ (locate on site plan) Number and configuration: wit Depth-top of liquid to inlet invert: nla Depth of solids layer: nta Depth of scum layer: Na Dimensions of cesspool: rda Materials of construction: Na Indication of groundwater: We inflow(cesspool must be pumped as part of inspection) nfa Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) rVa PRIVY: (locate on site plan) Materials of construction Na Dimensions: nla Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na (revised 0427197) a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 36 Seans Circle Centerville Charley Pires 1117197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) LO O 0 0 (revload04)27197) Pay ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 36 Seans Circle Centerville Charley Pires 1117197 Depth of groundwater. 12, Please indicate all the methods used'.o determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting moperty, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, instal�ers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revl2ed002TM7) page 10 of 10 4 COMMONWEALTH OF MASSACHUSETTS RECEIVED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA IRS DEPARTMENT OF ENVIRONMENTAL PROTECTION S E P 1 2 2000 ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TOWN OF BARNSTABLE HEALTH DEPT. TRU XE Secretary ARGEO PAUL CELLUCCI Governor DAVID B. STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A C,, CERTIFICATION Property Address:3 6 5aah Cie. tn�Cc �4 tV>,11� ■r#'bs, Name of Owner_ h Date of Inspection- Loa .Address of Owner M` V1 o- .dZ64% � Z.�Name of Inspector:(Please Pri1 �Q 1 L STF V f 1 � 1 am.a DEP pro system ins or pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Mailing Address: b55 Telephone Number: p CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: V Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails i 411� Inspector's Signature: Date: Q The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Rt.Coww,►,��� ''�ue.o�'^� �ar\� how Wr� }� @�Oltr `` Tror►� , '��.r��S� dr��� revised 9/2/98 Page l of 11 A i� Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION(continued) Oroperty Address: �� tt�`` '�-- C:'r� ��nt�►��\� )wnerc axvpi V'�9Cav1 rDate of Inspection: $I Z9Ib0 INSPECTION SUMMARY: Check A, B, C, o/ A A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not eval ated are indicated belo�^( COMMENTS: ..— t ai[ }y���� \h-•n r �� 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. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. nip The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Ir Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass TTT inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3� Sea", C i c o"At YN O' , Owner: Date of Inspection: C. C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ►11/7 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the T� public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance r11A (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) "-Property Address: 36 Saar Ctc'. Cer.Vw,4-A\&- Owner: Debbie O�Sah Date of Inspection: Q I z9(b0 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or / .cesspool. v 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach P q Y Y Y P copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: J� The following criteria apply to large systems in addition to the criteria above: itllt The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply V 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST _� Property Address:,% beaw Ci`. (.-AuW.r tfit Nil Owner: Date of Inspection: z5(00 Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Y No Pumping information was provided by the owner, occupant,or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. V The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: t/ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)] V The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION operty Address:�� �JPZ h �.ir. �e+► r i�� mr4- _.Jwner: pcbb�e. C)lsdr -Date of Inspection: g'Z�1V0 FLOW CONDITIONS RESIDENTIAL: Design flow:_Ug.p.d./bedro m. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow 44A Number of current residents:_ Garbage grinder(yes or no):_JlQ Laundry(separate system) (yes or no):_, If yes, separate inspection required Laundry system inspected (yes or no) ft 0 Seasonal use(yes or no):$Q Water meter readings,if available(last two year's usage(gpd): A 114 Sump Pump(yes or no):jl•Q Last date of occupancy: Qrtr►"e,% } COMMERCIAL/INDUSTRIAL: Type of establishment: n i1 Design flow: gpd�j Based on 15.203) Bqsis of design flo �da Grease trap present:(yes br no) NO Industrial Waste Holding Tank present: (yes or no)40 Non-sanitary waste discharged to the Title 5 system: (yes or no)Au Water meter readings,if available: n Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION ----NMPING REC RDS and source of information: System pumped as part of inspection: (yes or no)120 If yes, volume pumped: A gallons Reason for pumping: �Tr{ TYPEpF 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other n I� APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C � SYSTEM INFORMATION(continued) ?roperty Address:1�^+� Z" Ci'r. Ce-""SAC- Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) l� Depth below grade:23 Material of construction:_cast iron V40 PVC_other(explain) Distance from private water supply well or suction line Diameter. Comments: (Eondition of joints, venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) It Depth below grade: Material of construction:concrete_metal Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance—(Yes/No) Dimensions: L I Sludge depth: of Distance from top ofsludge to bottom of outlet tee or baffle:27 Scum thickness:11 _ it Distance from top of scum to top of outlet tee or baffle:_ Distance.from bottom of scum to bottom of outlet tee or baffle: 1� How dimensions were determined: T�Me.'b►sU e Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, epth of liquid level in relation t outlet invert, structure integrity, evidence of leakage,etc.) 101 GREASE TRAP• (locate on site pla ) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) `rop"Address:�� 5P2x^ Cir• ` t.'A Yw v-1V _.dwner: UV66e ahoy, Dace of Inspection: $�Z� 166 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present. Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: omments: mote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plant- ' Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) vroperty Address30 5t a•. Ccr Ce,,.,e.rv;\ka_ rn r► .Owner: Qebbsc v\Sov� Date of Inspection: SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number:/00c)" �.,• Lew, Q leaching chambers,number:A_ leaching galleries,number: leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of h draulic failure,level of ponding, damp soil, condition f vegetation, etc.) 1 rue Vr­NN)i CESSPOOLS: (locate on site lan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: ')epth of scum layer. _Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY: (locate Osite plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,^ \ _C SYSTEM INFORMATION(continued) '2►operty Address:3rG Sir Cif. �t -A\e—. iwner: �blo i e. a�Sbr� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 A t- Z� R Z: Sot 33 _ 46 Qe tk t 7 d revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36 Soh Gt, �--Owner: b\Dbi f_ Date of Inspection: oo NRCS Report name Soil Type. Typical depth to dVoundwater T USGS Date website visited fl Observation Wells checked NO Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Iq Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) VbG w)�Ps cNwaTS j AND tr�a revised 9/2/98 Page 11of11 TOWN OF BARNSTABLE LOCATION LSE41'J ClXe,eE SEWAGE # VILLAGE ASSESSOR'S MAP & LOT/76--6j;-r-eo7 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /�� .sr m �� 2'�Ily G✓r�P LEACHING FACILITY:(type) �f— , (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t l fa -1l400 . I � I r I V No-- Fes$ .............. THE COMMONWEALTH OF MASSACHUSETTS 1-74 425--7— 00-7 BOAR® OF HEALTH TOWN OF BARNST � tZj co pR o v D Appliratiun for Diopuual 3Purk turi t t Application is hereby made for a Permit to Construct ( ) or Repair ) an di idual Sewage Disposal System at: y_ ........... . - 2c�iu .................... b�-..��...... �A J— ation-Address �Q or Lot N.. __ /J .................. Gl�� ...... Owned ... ......_.S._��........ = �'�i ....,Ce j✓/v _ �........ ....... CU 16U Add ss �r- ------------........----------------... r�' r ',ay 1r.Z6..................................................... Pq Installer Address U Type of Building Size Lot! ,, _OW.. Sq. feet Dwelling—No. of Bedrooms.................... ................`v3.................Expansion Attic ( ) Garbage Grinder ( ) a e� Other—T yp of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . W Design Flow.................. .................gallons per person per day. Total daily flow...........c,, �..................gallons. WSeptic Tank—Liquid capacity/L0..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length................... Total leaching area....................sq. ft. Seepage Pit No.......c=P-_ Diameter......Zo_•-___ Depth below inlet.....6.1....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-----------------------------------------------------.................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth'to ground water........................ Ps Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ a •••-•-••---•--------•--•••-•----••---••-...--------•••-•-----•......--••----------•-------------------------------- Description of Soil------------------�.✓ ..... i '1_42 _Sgw....... Q_.... --- x V -----••-•-••--•-•--••-------•-•••-••-------•----------•----•----------------•---•--•-•....--------•---••------•••••--•------•-•--•-------•----••-•••--............---- W -••----••--•------------•-------•--------•-•------•-----•--•-•••-----------•-•------•-•••----•----•--------...•----------••----------•-••-----•- = U Nature of Repairs or Alterations—Answer when applica.ble._---_ %d .__ �?_�.Sh -------------------�...............-- 5.s2—e- -= Agreement: _ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the Y p p y health. system In operation until a Certificate Signed fiance h be n Issued the board of ✓y Application Approved By .�;� ./� ............... - �`� .................... ........ Date Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------------.............----------- ---- -------------------------------------------------------------------------------------------------------------------- ------- -- .------------------- --..--- Dare Permit No. ------ --� ........... Issued ------Zj�'.... ��/ Date x40 THE COMMONWEALTH OF MASSACHUSETTS '�7o Q5.7- CIO7 BOARD OF HEALTH TOWN OF BARNSTABLE ApplirFation for Diapoii al ark ;C u%a; ra�irtilaaipermit Application is hereby made for a Permit to Construct ( ) or Repair�( an Individual Sewage Disposal System at: y_ Cf ........... -••••----•----•----•--•...... ......................................... Location-Address or Lot No. ........... c��c may........ .... �1 ..._. -------------------------•------ Owner Address aril %7J <<��Nl /I �Ji�� 5.. -• - q � Installer Address !Sq. Type of Building Size ....S . feet V a Dwelling—No. of Bedrooms...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ......................... Design Flow...................... ...............gallons per person per day. Total daily flow-----------7 f1....--------------gallons. WSeptic Tank—Liquid'capacity,./-. '?.gallons Length................ Width................ Diameter................ Depth........... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No.......c-_�------ Diameter.___-.------- Depth below inlet..... ....... Total leaching area..................sq. ft. 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......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -•••••••••--•••-••••••••-•••••••-•-••-•---•-••••--...............-............•....................................................••........................ D Description of Soil------------------ -. �....IDA!!1.. €..Sl. D/Z_ `- •-�- �'/ = t n. tx U ------------------------------- •----------------------------------------------------------- ----------------------------------------- ------------------------------------ •--------------- •--------------- W UNature of Repairs or Alterations—Answer when applicable_...__ l'1_..._...Z�/.'Q;P_I_ 1P!?-.._Gtl o? ..------•--••-------�--'�- ........... .............--...................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued y the board of health. Signed .................1..// /D -- -- ; /9 ----- Application Approved BY " ' ----------------- ----------- ---4 .-= - -----------------_------- ---�Cf`----��'" Date Application Disapproved for the following reasons- ...........................................------------------------------------------------------------------------------------------- ...............................................---------------------------------- ------ ------ .................................................... .............----------------------=-= Permit No, .............. ......... Issued ----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certtfirate of Contlatiance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired GK ) by -..............................---------------- ------------✓ �.07 7 nos 2U�77��J Installer at ---------------- ,�lv-----------`--=S -------C/.6G!1 ------ - ..iITJr'. L//LL --------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. Gf, 1 .v��7 .... dated-.- -.�'...��� -` 7 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEEITHAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------- `' � / �=%70 /s%� Inspector --------. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Disposal Works Taaitstrudiuii Permit Permission is hereby granted.........................��< -4-Q -....__.�d�sT��U�/G� to Construct ( ) or Repair (-<)• an Individual Sewage Disposal System at No........................................... ln------...`= A )----C'/ 4 C 1 .C%I//LLB Street Q as shown on the application for Disposal Works Construction Permit�' /�.� ated------ �� r.. /` — f j L"`- s Board of Health / DATE.............. .....------ ---- -••-•----- ----- FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS LdCATION y SEWAGE WERMIT NO. V LLAGE 7 ,PevlL INSTA LLER'S NAME i ADDRESS Il Lo12ll"- 4 ,12oj . c- B U I L D E R OR OWNER �S ,t DATE PERMIT ISSUED Z 2 DATE , COMPLIANCE ISSUED y'_ 7 �N 'w 3a� D 3G` D D No............... Fss....` ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town...-. .. --.-..OF...-Barnstable ....................................-............ Applira#ion for Dhipvii al Works Tomtrurtion Vantit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at:" Lot 7 Sean' s Circle, Centerville ...........................•---.......--•--.........._........__._..........----••-•---••--•------ --...--•--...-----------•...-•-•--•---••-•---- ............. cation-Addr ss or I of No. kT Owner Address �ck ------------------------------------ ........... 1 3i. ...--------------------------------......._..._.._ Installer Address UType of Building Size Lot...16Y.3.21 S....... q. feet ,., Dwelling—No. of Bedrooms................3-.........................Expansion Attic ( ) Garbage Grinder (no) P4 Other—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------------- - W Design Flow_________________________ 5______________gallons per person per day. Total daily flow....3.3.Q................................gallons. WSeptic Tank—Liquid capacity__10.0Qallons Length.__ i_6et._ Width___41101niameter________________ Depth___,!�lI-- x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------I .......... Diameter....1•Q'___..... Depth below inlet.......(!_......... Total leaching area2.6.'].........sq. ft. Z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed b3Cape...C-od--SurvzX---ConsultantsDate------4/1-1{79------------- a Test Pit No. I......2.......minutes per inch Depth of Test Pit.......l2_!...... Depth to ground water_.none________-- G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •........ -•--••--------------------------....... ----....... ----••-------------------•-•----- •--••------ •.......... •••••--•-•••••-•...--••••-•-•----••--_--•-- O Description of Soi1MmO._5___Iataad_.1oam,___$._5_-Z_._."�.___s�.lbs4i.l.,_2-.-`3-.6.-Q-RA mac 7-------- x b._Q-12..11._me_d.---�caars_e.__sand.------------------ (� (?F•c n7----------------- -------------------------------•.------------------------------------------•----•------------------------------------------------------ P� ti -............ U Nature of Repairs or Alterations—Answer when applicable.__________________________________________ _g- - TH AS ----------------..............................................E..................................................................... ©•...........- -----•-•••-• 7 --r1........... Agreement: " MONAHAN No. 20945 The undersigned agrees to install the`aforedescribed Individual Sewage Dispo stem in c ce with the provisions of iITiLI. 5 of the State Sanitary Code— The undersigned further agr O� ��� ."ystem in operation until a Certificate of Compliance has been issued by the board of health. TONAL E p, Sign --- ... . ........ ........ .......................... ••-•-••••-•G -•-- Date Application Approved' B � - --------------- ------.__-S7_7;�- ------•--- PP PP Y �� � Date/ Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- ----•-••--•••••••.............•-•-----•-...-•--------•---•---...-•--••-......-•-•-•-----•--•---••-••••••-••••-•••-•••••••-•----•••------•--•-•-•••.................................................... r --•--Date PermitNo......................................................... Issued_! _-r--- / -7-- -•---- t Date } y9 ... Fim.......!:.%............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town OF....Banst ab!. .. .. Al'iphration for Dispuoal Vorkg Tonstrurtion Prrutit Application Is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Lot 7 Sean's Circle, Centerville ................__.._.................-•-------............---------------------......._....... --••------•----.....----•---------------••---- - .................... Location-Address or I of No. Owner Address a ..... 1 .Tam-i " ------------------------------------ ►i�,mw. i.'�.. Installer Address Type of Building Size Lot... 6x 2,1--------Sq. feet Dwelling—No. of Bedrooms...............3..........................Expansion Attic ( ) Garbage Grinder J10) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures -----•------------------•--------------------------------------------------------------------------................................................. W sign Flow................. ..... ..............gallons per person per day. Total daily flow.... 0................................gallons. WSeptic Tank—Liquid capacity 3,i100gallons Length.__.&!.. Width---4.!-1Q?#Diameter-._--__-_____ Depth__. ,?61!.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......I----------- Diameter...10.1......... Depth below inlet..... 6.!.......... Total leaching area267.........sq. ft. Other Distribution box (x) Dosing tank ( ) z Percolation Test Results Performed b}fa d.-3;p� .-a�iL1 1fi 3 __.fC g � Date___._.6/ ,1/7,�. a Test Pit No. I......2.......minutes per inch Depth of Test Pit-------121...... Depth to ground water..nO.-4g.......... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------------------------•---------------------------•-----------------------•------------......................................................... O Description of Soi*..G�.0.,5...WO1Od-.loam-r--. .Coars-e---sand---__.. x1................................ .- ._Ili l C. ic"? '"3 ---E<Qn&-----------------------------------------------------------------------------------------------V W -----------------------•------------------------------------------------------------•----------------•------------•---•-----._..... VNature 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-issued by the board of health. F.: Sign ...... ------•----------------•------------------------------------- -------------------------------- Date Application Approved By.. f'.. -------------- D 7---------.- Application Disapproved for the following reasons--------------------------•-••--•------------------------------------------------------------------------------- ------••...............•-----•-•--•••-•---•---•...-•-----------•-•-•.....--••-._....-----••••---•--•--•--••----••-•-----••-•-••-•---••--••••----•-----------------------•----------------------------- Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS `N BOARD OF HEALTH :............OF..�p jj.f.j.-AbJ..g....................................... (Irdifiratr of TomptiFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by '0t.1 --�" �-M------- -- .......................•---------.....--...-- at.......h�J'�1..---•�-.......UNMS..... -�TR�!.*e�A....1- taller---- ----------- 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 No. __-: ._ .•.__- �... da.ted-------- "__, _-... . ............ THE ISSIIANkE OF HIS CERTIFICATE SHAL OT BE CONSTR E® AS A GUARANTEE THAT THE SYSTEM WILL CTI SAT.IS- ORY. DATE..........::..:. ........,✓... Inspector........ ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �, ......'�". .w.........:..........OF.. t :" A ....•--------........................... ►�.� N -.... ..... ... FEE......... ........... Disposal Works Tonotrttdiott an it. Permission is hereby granted.....VET01u w._.. !% to Construct (vo� or Repair ( ) an Individual Sewage Disposal System as shown on' the application for Disposal Works Construction Per ....... ted..-�/�^_. '�'" ............ r Board of Health F: DATE---------� S. ........................................ = , FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS " SOIL LOG �_�_ !"►lAtT ONE. ...LOAM Ff LL.•� III"YA% WdR1T? • mug ` 1000 BOX I,.o•,e 1000 GAL. o I 1 10 MIN GqL i�� ;. PRECAST OR a F` 24" Tsr s+nry SEPTIC I...;•,• BLOCK • � MIN TANK s' 1 '•a;,a; 'SEEPAGE • ' . : I Mfcx ll I • :• • nos 0 t •°�d� PIT • I .yew P.?.LR_.� 20' MIN. -- .; • • d +.� ArFR FOUNDATION WASHEOL STONE ELEVATION SKETCH ;— lot --� ' PERC. RATE: - SCALE : I" = 4' TEST BY ' + TOWN INSPECTOR 2 77VO�r 7"W-0 BACKHOE OPERATOR: �— TEST MADE ON : _ AV,,!g.r 4 0 c19"r&-.v --�— f/,Bt o d iY T!/.•.s,•�' G, /f'7 Q '.+�.vv �r .c+a,E3 C.ca.+st'0.�2.��p' ,7?� Tt�.r� ?.O�!/•�•S+r�. .S�►T-�i'�$�' �..��G"/.G`� /"l.E J+'`l".S • HDFAlq,� cy� UAMEs 1 P. * .LAPSLEY. ,Iy No.22597 ti [rl /4t Y h C lot f x h fit' ..� -•�•""".....•• oo--- L-.cw,HV v .atT�f�x.S..,tt �� j l004���i• . M t1 4m OF q CONG. �c TH ' AS roP r411, MO '-' NAHnN Fc a/oi.o�, .` No. 20945 7� . 9sX'7 / / .40 7" '� a i 17 1 ' i, EST/MRT�,p D.o�� Y FL,oW • 3I3EDRoop�„S Y �10 ��aI.�D,�r�,(3.1L, = 33c• -2) k1AX. AA,k0WA8 k F DAr,c Y Fl-a vJ FOR, TH,(-5 5404 A4A.5 rE6 -'V X 2,S G.P.0 !34 77-6^* 79 s. x i.a Cr-P. p.l s,r 79 Cr,P.0, r 7"0 7,e-��. Z61 3.F. S99 gyp, a- � � x ELEVATION SCHEDULE T PROPOSED SITE PLAN a 1. INV. AT FOUNDATION 2. INV. INTO SEPTIC TANK , 98,zz SEWAGE SYSTEM DESIGN 3. INV. OUT 'OF SEPTIC TANK = 97`97 Al_re ITa 4, INV. INTO DISTRIBUTION 80X x-97 , SCALE: 1"=�p• AlA+f" 197f t i 5. INV. OUT OF DISTRIBUTION ' BOX _ 97,70 C - 74q-2_ 6. INV. INTO SEEPAGE PIT = grEoO CAPE COD SURVEY CONSULTANTS ROUTE 132 ' 7 BOTTOM OF PIT HYANNIS ,MASS. . i `.