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HomeMy WebLinkAbout0019 SHUBAEL GORHAM ROAD - Health 13 Shubael Gorham Road Centerville CP A = 171 132 Commonwealth of Massachusetts �v ,o Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < V � 19 Shubael Gorham Road Property Address { Harold&Marguerite MacNeely Owner Owner's Name/ information is Centerville V Ma 02632 10-9-19 required for 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. Important:When filling out forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 f Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ■❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey �� "°" ""'°" 'Vie:ZOt8.i0.15 taM:a)-0°Yp 10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ' �n Title 5 Official Inspection Form ±= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �= 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection 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 ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 « / 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 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 %day flow ❑ O Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 'El 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. 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road u Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection 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 No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ 0 Has the system received normal flows in the previous two week period? ❑ ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Q ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? E ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? ❑ a 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ a 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)] t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 2 Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes [j] No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes 0 No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: ***2018- 108,000gallons 2017- 45,000gallons'k** Sump pump? ❑ Yes 0 No 9-30-19 Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts 1. ,p Title 5 Official Inspection Form t f' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road V� Property Address Harold&Marguerite MacNeel 9 Y Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped May 2019 Was system pumped as part of the inspection? ❑ Yes K No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Offdal.lnspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road V� Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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 components, date installed (if known)and source of information: Tank and original pit 10-30-1978 new pit added 7-23-96 per COC Were sewage odors detected when arriving at the site? ❑ Yes H No 5. Building Sewer(locate on site plan): 216,E Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments oncondition f joints;venting, evidence of leakage, etc. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road V� Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1'611 Depth below grade: feet Material of construction: W 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 allons Dimensions: 1000 9 511 Sludge depth: 31" Distance from top of sludge to bottom of outlet tee or baffle Orr Scum thickness NS Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle NS measured 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.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . . 19 Shubael Gorham Road L� Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every a e. City/Town/Town State Zip Code Date of Inspection p Y P P 9 D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm resent:p ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 y cam, Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): NA * 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: El leaching pits number: (2) 6'x6' pit ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts r �m Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection 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.): The SAS was in working order at the time of inspection. Both pits had 1' of standing water when viewed. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 9 P Y rY I 19 Shubael Gorham Road V� Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road v Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately Assessing As Built Cards �+.f..r .t U01 N l!i'MfiICNS lAL4L.b. - cocxnorf GaP"A#r:.RV. sm of a ,. vat.ys�:a, t" w"7"'rr�rlh��. nss�e§sox•s�+A��t.qr 1 Z7_x.��. 00r xs a T7r 6o 5f tvwiair a wsrr>Ne No •' s L" +C sff>Fyrirw�ru�nt rrs+acrrir Jd� C.s�l " t�ACkiniol5wcnsrrr;teyac> to l ZI—M ts.o1 "a.'of=iafimtooms ....... ]BUMMM oft dwmmaa¢ N .%ne✓✓ . FOLVO I'DATB: 10-: 1i!, COMPL.LANCB IDAYT3: 5ayasadims Diataneo:Helneeothc; MulsuidiewiS{u:,ia proeuawerar TaWa�aad B°unm cif[ieoching F°cllity. Feet rvivaft waw supylr WeH ow LZKhmg:Faanty titwY.wew�ezis+..: - ,°n site or wStLin 200 feei CC M.t']Ktling faraliity) _ Bdlp,�Wetland and-L awlung exist wWlhin�Oo feet r�, 'tacey) ..'Yee 110 .'�" . .:___ _...__�- ems• Wile of, ts: i I' it t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15, Site Exam: ■❑ Check Slope 0 Surface water ❑■ Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 12'feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 10-30-1978 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: , ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r c� Commonwealth of Massachusetts �n ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 19 Shubael Gorham Road Property Address Harold&Marguerite MacNeely Owner Owner's Name information is Centerville Ma 02632 10-9-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked 0■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed 0■ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Miorandi, Donna From: MacNeely, Martin <mmacneely@commfiredistrict.com> Sent: Wednesday, October 23, 2019 8:59 AM To: Miorandi, Donna Subject: Septic System Question Follow Up Flag: Follow up Flag Status: Flagged Hi Donna, 1 have a question about my parent's house, 19 Shubael Gorham Road, Centerville.The property will be going up for sale soon. I had the title V inspection done which shows a 3 bedroom system. My parents only used it as a two bedroom home. Would three bedrooms be allowed in this zone?� Thanks for your help. Martin O CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe! ' 10 1 d TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 0 PART A CERTIFICATION Property Address:_j q S(Q d(�e k 60V4--"'% C,,A ruA L �) � o,�u.l� � h FEB 0 3 2005 Owners Name: TOWN Or BAr�NSTABLE Owner's Address:_ s� HEALTH DEPT. e Date of Inspection:_ Name of Inspector: (please print) A. hP Company Name: du f4 t c Sua Mailing Address: 3 �-c r S l.✓ {-��,,�„�( A14 0d-6YS �CEI Telephone Number: (�Vg) 9 q DO CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: J dSJ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and CommentsjSiUyL �ZI.Y /1✓��� �`'9���"I 70 ****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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner:_ �"Ka Date of Inspection:_ !I/9 ✓1 Y Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exists.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND ex m: t000l Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed ✓Distribution box is leveled or replaced ND explain: the system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced Obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART A CERTIFICATION(continued) Property Address:_ i q S�u a 1 1 ,, 2,d Owner:_ � �,��q��� ( l�CI.0 Date of Inspection:_ i(l r" C. Further Evaluation is required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1) (b)that the system is not functioning in a manner which will protect public health,safety and the environment: _Cesspool or privy is within 50 feet of a surface water _Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health and Public Water Supplier,if an determines Y ( PP � Y) e es 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 Y P rP Y (SAS) 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ q A � /I jvclm- Owner: 1l1aw"Id OWE Date of Inspection:_ 11 i y J S— D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes J��No/ I Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool/ �J Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)the system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes no _The system is within 400 feet of a surface drinking water supply __The system is within 200 feet of a tributary to a surface drinking water supply __The system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_0 q �L Lj Owner: D0AZI1& ✓8/zWA Date of Inspection:_ t l[yd d 6 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health i/ Were any of the system components pumped out in the previous two weeks? ✓ /Has the system received normal flows in the previous two week period? Has large volume 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 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, g Ve 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: Yes �To ,�/ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_ '�4 e) .1( Owner:_ &blLl rj 'tA Date of Inspection:_ t�l�� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): C�' Number of bedrooms(actual): ,/ o DESIGN flow based on 310 Cl 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): t V [if yes separate inspection required] Laundry system inspected(yes or no):&D Seasonal use(yes or no):Nd , Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):10 'O 3- r Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records t/ Source of information: �{dw,c.CW ul1 - IffK '�dpf/11*r Was system pumped as part of the inspection(yes or no): Al V If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _ZSeptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and sourcc of information• Were sewage odors detected whefi arriving at the site(yes or no):AV OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ t `i � �� � /C�1I Owner: Dc"t' fj igrz"Ov) Date of Inspection:_ th gl,S- BUILDING SEWER(locate on site plan) Depth below grade:�_ Materials of construction:_cast iron ✓40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓(locate on site plan) Depth below grade: 1 S& Material of construction: ✓concrete metal fiberglass_polyethylene_other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: E5441-t :6- Ac 2 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 5/9-?iG '7* /'n, GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ AoLd a Il" Owner: ��'A draft'.)� IJYv Date of Inspection:_ `it J S TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:Alkaz.l Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of tox,etc.): L v �tll'a b 12M PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ �� Ad. Owner: Date of Inspection:_ t`ty Ste. SOIL ABSORPTION SYSTEM(SAS): !' (locate on site plan,excavation not required) If SAS not located explain why: Type "'Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): 3 Li O 13 t '6CL IL M 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ !� C1 L-C'J yCffLo. Owner: d vILI-I'cP isf1l�vjll� Date of Inspection:_ l�t g�® - SITE EXAM �7 Slope A/�v� Surface water 1V&v4_s_Check cellar j Shallow wells � J 7 Estimated depth to ground water f9'_"'feet !� Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ,Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: 1,�51s D 'U1-0 Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: O o S'k- F0 a 33. o aS 30 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 3«k OdV i , Q �0 it � AID cc a 4-0 ,p: a,5- / 0 , }oG9 31 ' dit �r a TOWN OF BARNSTABLE . LOCATION lq SI U l 6 a y/1-41 A9 SEWAGE # V Z=:LAG ASSESSOR'S MAP& LOT - MSTALLER'S NAME&PHONE NO. A;3 !$IVCO `7`7S--6cUifc SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE:_T l D q _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ' on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by bo 56' ZS� ?sack o F Aaose MOP 17 No. par /,?x Fee 7o — THE COMMONWEALTH OF MASSACHUSETTS Z 1 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYtcation for Migool *pgtem Cou6tructiou permit Application is hereby made for a Permit to Construct( )or Repair vran On-site Sewage Disposal System at: Location Address or Lot No. Ow er's Name,Ad ress and Tel.No. Installer's Name,Add ss&and Tel.No. Designer's Name,Address and Tel.No. B CANCO 6 a xj-e r + A)Y'-Q- 350 Main Street Type of Building: . Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date "` a —'7 Number of sheets i Revision Date Al/14 Title At" SmAti _rvle 4 Description of Soil n-.j' n(AA 91 Nature of Repairs or Alterations(Answer when applicable) �_. I &&a->) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envirppmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this d H a th. Signed Date — 10 (� Application Approved by Application Disapproved for the Yollowing reasons Permit No. / / Date Issued par .. No. / ,� � - ,',.^�, ��� Fee COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Mizpaal *raem Construction Permit - r i Application''is hereby made for a Permit to Construct( )or Repair( an On-sit Sewage Disposal System at: 4 Location Addr s or Lot No. O er's'Name,Ad ress and Tel.No. Installer's Name,Ad*,&ag TOMCO Designer's Name,Address and Tel.No. 350 Main Street 6^x-�c r + N yQ- F W. Yarmouth, MA 02673 Type of Building: Dwelling No.of Bedrooms - Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date O -3d -7 Number of sheets 1 Revision Date d)14!q Title AI AY% Sm xt( 1"n c. Description of Soil $ >p o j' A(Art Nature of Repairs or Alterations(Answer when applicable) 1` X Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Env' mental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this d of\H a th. Signed Date Application Approved by :.Application Disapproved for the Vollowinng reasons Permit No. ! 6 A a / Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(Wol'on by r.4ftJCd for IDJ71 WAI/ as /9 Sha b.*a/ �arhAlrl 1"r1/4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is coonnfditioned on compliance with the provisions set forth below: *' __LX _ r No. —a a Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migoal *p!gtem Construction Permit Permission is hereby granted to C,a G to construct( )repair( -<an On-site Sewage System located at 7 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: � Approved by E LO CAT ION 171 y SEWAGE PERMIT NO. VILLAGE U/L1— ,!� 117,09 ' IN.STA LLER'S NAME & ADDRESS Goi a i� ?d q D ��ys�s:vus •�� :s B UItDE R OR OWNER DATE PERMIT ISSUED _ a DAT E COMPLIANCE ISSUED,, j✓,� _• ---_�,�- . r �, - �I � �� f y ``�- -, cS's cs—` r , N0. LOCATION SEWAGE PERMIT V I L L INSTR:::LL:ER'S NAME i ADDRESS D /lly/1'5;ONS ow 0 U I'L DER OR OWNER 5 5'i�JVAX, yN� DAT• E.::: ,P;ERMI-T ISSUED DATE,_ 40MPl1ANCE 1S'SUED. ,i - �-7�- • __ - 1F�5 E7N1 EIJT' Laat LNf 1`LOW 1 ib S , sso wp,D. { SEEF-mc- TA"-4w- = 330,. ISO % • 4-95 E•.P.D. / O ! - �. �. U Ste- t 000 6.4 L ; 41 _ SUS- ALL AQEA z IrjO Kp� SF ,c Z.S * 3 TS G.P.V. Q D. ' Tc7rAL* DESIGW s 42S G.RD. I oU TbTo L tea:u%( ouLY�T . Flow * 330 6�Pu. t ., :r.. . . .��. of L) t AICHARUWX LP A. SAXTI:H ALA. ZA' Q�STEQLp4 n. 0r1 ti fro Tar F'wo•�oo.s + • �l"tea loon uNc ' :;i ��•.,.�.e � ,,i`� Q AP 6r tu/• GAL• Ji.. ±n.! rf. Iz -nI // a'• �••' 1 J �r fi Jr• IZ .4:;•... ��F ,'yy TAWK: 'O A•:, - _.r •1. �,j -:%'•�t 4:�• qI4• ,.} ti ]'A 'Dr. ... i ..w.•. ,.•� 4 {' .' + •,!.• ' GAL. r v , •-";.. .,�, , _A. ...• "1� �,�: )`.EACH 1 FlT y 6QTIPI1cD PLC)r LO ATtot`J C..EWTE►Z.�I Wa�2 I -do � tol�oh8`1 G612TIF�{ Tt-lAT THE t-ov+.IDATloi.1 54lawN FLAW S MiraV �.IGE %4 W G 064 GOAAPLYS w I n4 Twt=- 51 IIE_�.I /SAlL7 SE�'rL3ACK. Vr-qu1QENtGWTS op -r"e- �T owtil of "BA�etJe,TABL� •� PL. DIL• 304 PC. 2.2 RC G I�ct.rts� 1' W o Su eV EYo 1-5 T141-S FLAW IS Wo'r E5,4gC,o Or.•1, AW OST-IZV_II.LG o dSC' UAAr--lJT -509VM-11 j TI C—. OFcrS&T-e. ��acW�a A1�Pt`.1 GAIJT br BE usmo To oerceMiNc Lp"r 1_1�•1`� � G No.� 5--��5 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z(ppYication for Migozal *pgtem Con.5truction 3permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Ad s o Lot No. Owner's Name,Address and Tel.No. Cu;/)� /9 s1 v�.��� ��116 YV Assessor's Map/Parcel �� �� - 93017 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Ulm LT -B1,N M F sf�>L Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when an plicable) 4 t Date last inspected: Agreement: The undersigned agrees to ensur a construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions o itl 5 of the Envir ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been iss. by �.—, Signed Datet2 Application Approved by Date �` �8 0 Application Disapproved for the following reasons Permit No. S 0 SS Date Issued 7_0 '�'/ _'. :S.-� �.��-._. -�.w..r.,+v-w ♦ �'�wl.:YsY.�.�.�3.11a.1.+- � .. F ,'-,�. 4. • ,.� b �, M , 11 +.. J _ No._or � Fee AIV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for �Digogal *p.5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Add re s o Lot No. Owner's Name,Address and Tel.No. r9 Assessor's Map/3 367o Aqm RP Awl? ,ce1 Ow©� 3 0 p Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �7 7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 'Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) P 0e—F Z_S'71* 1)r '" , -i Date last inspected: f Agreement: The undersigned agrees to ensur A e construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Eby itl 5 of the Envir�t ental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss e t. Signed DateO� es Application Approved by - :. - ,. := _ - — - Date'r Application Disapproved for the following reasons t h , Permit.No. C�),Oc)S Date Issued /® O ———————————————————————————————————— --- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired'( Y14.Upgraded( ) Abandoned( )by _ U-(-Nop at I a Imo, _Q) 1-,A.+n W-ey C, V �_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. l` >'5 C> dated �� / � Installer t l_.�,U�C"r, t' s), Designer The issuance of this ermit shall not be construed as a guarantee that hie,system illfuncti',n as-designed. Date Inspector\.1 --------------------------------------- No. ��JCi �— lJ S�) Fee _r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigogar *pgtem Construction Permit Permission is hereby gra ted to Construct( )ff Repair(Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Cons tr ct ion must be completed within three years of the date of this p- lk Date:_ / ,ot �r Approved