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HomeMy WebLinkAbout0499 SKUNKNET ROAD - Health 499 SKUNKNET RD. CENTERVILLE <, A = 169401 ? 0%Fford.. NO. 1521/3 ORA �:�� ' 10% Commonwealth of Massachusetts � " /0 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville V/ Ma 02632 10/8/2020 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 A. Inspector Information S jjIq�'q- filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane 41 9 Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification 1 certify that: 1 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 10/8/2020 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 +� Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 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 property located at 499 Skunknet Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 3 500 gallon precast leach chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown 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 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown 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 ❑ ® 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 Commonwealth of Massachusetts is Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow El ® 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 public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �a 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth: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 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. CityrFown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown. State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: system repaired 1-31-2001, tank original 1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 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.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts +- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. CityrFown State Zip Code Date of Inspection 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 ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .., 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 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.): * 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: ❑ leaching pits number: ® leaching chambers number: 3x500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tl� 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown 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.): s.a.s consists of 3 precast leaching chambers in a 35'x10x2'trench. Leaching facility was video inspected from d-box and was found dry with a stain line approx 6"from bottom. 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.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): 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 -u- 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 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 c v 3 44 T3 �2 ,A2 2� t�Z 3'Y A36 93 3-Ir 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 �a 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is. Centerville Ma 02632 10/8/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 499 Skunknet Road Property Address Capeabilities Inc. Owner Owner's Name information is required for every Centerville Ma 02632 10/8/2020 page. Cityrrown 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 ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARN-STABLE, ,LOCATION �ZF S J k v /L 1614 r (c4 SEWAGE #7,42 0 VILLAGE T , ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. A-.<o a"' Q -7-2 SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) �4 L 'e (size) f Q v NO.OF BEDROOMS BUILDER OR OWNER >°G' PERMITDATE: O"OL-6 I COMPLIANCE DATE:�- Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 Weiland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r .. �� ���� r� tit. �/ � �. '7 ^ , , n n �-L ,' � s� � '�-t .. - t�o�-4 _. TOWN OF BARNSTABLE LOCATION 1 �I VILLAGE ASSESSOR'S MAP & LOT S NAME & PHONE NO.:gJ- MA ky, SEPTIC TANK CAPACITY A" LEACHING (slze) �OG� NO. OF BEDROOMS 00 PRIVATE WELL OR PUBLIC WATER BUILDER OR O WNER , V 4? ISSUED: DATE COMPLIANCE ISSUED• ,eta No Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Mie;poml bpztem Construction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assgof'slVra�Mnet Rd. e t vil Daniel & Deb Dwyer Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms_,•4�) 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 Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting of a D-box and 3 H2O (heavy duty) precast chambers with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi oar f Health. Signe m Date Application Approved byZykd����_)tDate Application Disapproved for the following reas s Permit No. Date Issued TOWN OF BAI NSTABLE fig. LOCATION L�� J /� ✓ .y h1C i ��/ SEWAGE #7,1-1)/��0 1. . VILL -'%�-. ASSESSOR'S MAP & LOT G—/U( INSTALLER'S NAME&PHONE NO. I SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3`� $ AZ° L (size) v S`�✓— NO. OF RFDROnms Y i BUILDER OR OWNER YJ.' PERMIT DATE: 6 % COMPLIANCE DATE: j Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 I .. ilk jt IL { t 9 I 1 Ig1 4 .�... No. Fee If THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2ppl cation for Migossal *pgtem.. Construction Permit ti { Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. } AS (9'Ssnet Rd. Cent rvi Daniel & Deb Dwyer Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service $. P O Box 1089 Centerville 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 SoilSand t% Y t Nature of Repairs or Alterations(Answer when applicable) Title-5 leach systefft eensisting a imp— precast—ehaazinb . with rendoll -mound. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation'until a Certifi- cate of Compliance has been issued by this Board f Health. Signe Date Application Approved by' 4/1 14 Date Application Disapproved th d llowng reaso Permit No. Date Issued --------- —————————————— ---=---------- ,I THE COMMONWEALTH OF MASSACHUSETTS Dwyer BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO C> RTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( ) Abandoned( )by WM P Robinson Septic RRrvi nim at 499 Rknnknair RH s CPntervi 1 1 P has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction PermitNAM1,6D ted Installer fit. E�b.75� S r. Designer The issuance of this permit shall not be construed as a guarantee that the syste will fund 9desig"ed. p Date r l Inspector No. �v (P r ------Fee THE=QOMMO"NWE*LTH 6F MASSACHUSETTS ` PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Dwyer MiOpogar *p5tem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 499 Skunr:net Rd. , Centerville 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:Construct'on must a completed within three years of the date of this- emut '` Date: Approved by �' - 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WPTHOUT DESIGNED PLANS) 1, William E. Robinson,5�ereby certify that the application for disposal works construction pertnit signed by me dated %��C� , concerning the property located at 499 Skunknet. Rd,, c n v J i 1 e meets all.of the Mowing criteria: • The failed syste is commted to a residential dwelling only. There are no commercial or business uses associated th the dwelling. The soil is d ed as CLASS I and the percolation rate is less than or equal to 3 minutes per inch. There are n wetlands within Ilw feet of the proposed septic sstcrt► - • There;uc:i private:wells within 150 feet of the proposed septic system - There is increase in flow and/or change in use proposed There no variances requested or needed. • The nom of the proposed leaching facility will Wtt be located less than five feet above the tt>a mum adjusted groundwater table elevation.f Adjust the groundwater table using the Frimptor m od when applicablel • the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will UM be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3 /o B) G.W.Elevation +the MAX. High G.W. Adjustment DIFFERENCE BETWEEN A and B SIGNED : 1?i yl� ✓ DATE: G�l� -'t� ✓ (Sketch proposed plan of system on backl. y:heaM folder:cm ` �� 1 �- . � t. ��. .0 � 1 - � � Q ��� � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t V•v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 499 Skunknet Rd. Centerville, MA Owner's Name: Daniel Dwyer Owner's Address: Date of Inspection: 7-1 7-0 Name of Inspector: (please print) wi 1 1 i am F_._ . Robi_nson Sr. Company Name: William E. Robinson Septic Service Mailing Address:_P O Box 1 089 Centerville, MA Telephone Number: (5 0 8 ) 7 7 5-8 7 7 6 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.1 am a DEP approved system inspector pursuant too Section 15-340 of Title 5(310 CMR 15.000). The system: !/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: y):i�Zf 7 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hem&,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 approxing authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:4 9 9 Skunknet Rd. Centerville Owner: Dwyer Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or reps' ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answ r yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla' . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exist' g tank is replaced with a complying septic tank as approved by the Board of Health. *A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indi ating that the tank is less than 20 years old is available. explain: Observation of sewage backup or break out or hi static water level in the distribution g kup high box due tabroken or o structed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with a roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will ss inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: • Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 499 Skunknet Rd. Centerville Owner: Dwyer Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fai ' g 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 any)determines that the sy tem 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 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 499 Skunknet Rd. Teete�v}��e Owner: Date of Inspection: D. System Failure Criteria applicable to all systems:. You ust indicate"yes"or"no"to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow 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. L rge Systems: To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You ust indicate either"yes"or"no"to each of the following: (Th 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 ou have answered"yes"to any question in Section E the system is considered a significant threat,or answered in Section D above the large system lm failed.The owner or operator of any urge system considered a signific t 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 499 Skunknet Rd. Centerville Owner: Dwyer Date of Inspection: -3 1-B Check if the following have been done.You must indicate`yes"or"no"as to each of the following:' iNo 7- Pumping information was provided by the owner,occupant,or Board of Health r/ 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? I/ Have large volumes of water been introduced to the system recently or as part of this inspection? v — 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 i/ 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? 1/ 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 no 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 499 Skunknet Rd. Centerville Owner: Dwyer Date of Inspection: 1-31—Q / FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_�Z_ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): L b Number of current residents: L/ Does residence have a garbage grinder(yes or no): A, Is laundry on a separate sewage system(yes or no):A_ [if yes separate inspection required] Laundry system inspected(yes or no):,A6 Seasonal use:(yes or no):�t� Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 0 108,0 0 0 gal. Sump pump(yes or no): i1/4) 1999 113,000 gal. Last date of occupancy: 1,3/`O C MMERCIAL/INDUSTRIAL Typ of establishment: Desi n flow(based on 310 CMR 15.203): gpd Basi of design flow(seats/persons/sgft,etc.): Gre a trap present(yes or no):_ Indus ial waste holding tank present(yes or no): Non- anitary waste discharged to the Title 5 system(yes or no):_ Wat meter readings,if available: Last ate of occupancy/use: OT ER(describe): GENERAL INFORMATION Pumping Records Source of information: 9 5 a a Was system pumped as part of the inspection(yes or no):�i 0 If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP F SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —ivy _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 source of information: Were sewage odors detected when arriving at the site(yes or no): tv 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 499 Skunknet Rd. Centerville • l Owner: nwwer Date of Inspection:—7, 3 f-t5 J B LDING SEWER(locate on site plan) Dep below grade: Mate ials of construction:_cast iron 40 PVC_other(explain): Dis ce from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: ) ` 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) c Dimensions: G Sludge depth: Q Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 a Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outer tee or baffle: How were dimensions determined: 6 ) -0 L l- Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to utlet inve ,evidence of leakage,etc.): GRE SE TRAP:_(locate on site plan) Depth elow grade: Mater al of construction:_concrete_metal_fiberglass_polyethylene_other (expl in): D' nsions: Sc u thickness: Dista ce from top of scum to top of outlet tee or baffle: Dista a from bottom of scum to bottom of outlet tee or baffle: Date last pumping: Co ents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as rel ted to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 499 Skunknet Rd. Owner: nwPr Date of Inspection: -31�0 TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Mater 1 of construction: concrete metal fiberglass_polyethylene other(explain): Dimen ions: Capac• gallons Desig Flow: gallons/day Alarm present(yes or no): Al level: Alarm in working order(yes or no):. Date f last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: /(ifesent must be opened)(locate on site plan) Depth of liquid level above outlet invert: () Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PU CHAMBER: (locate on site plan) Pum s in working order(yes or no): Al s in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 499 Skunknet Rd. Centerville Owner: Dwyer Date of Inspection: ) '—z/—G l SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: j 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 S � CESSPOOLS: (ce ool must be pumped as part of inspection)(locate on site plan) Number and config tion: Depth—top of liqu' to inlet invert: Depth of solids I er: Depth of scum yer: Dimensions o cesspool: Materials o construction: Indication f groundwater inflow(yes or no): Comme s(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Material of construction: Dimen ons: Dept of solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 499 Skunknet Rd. ' Centerville Owner: Dwyer Date of Inspection:�i — 3l—o 1 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. 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 499 Skunknet Rd. Centprville Owner: Dw�zP r Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water i fefeet 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ho ou established the high ground water elevation: a !2 d �l r 11 DATE: 2/22/97 PROPERTY ADDRESS: •499 -Skunkne•tA Road Centerville ,Mass . 02632 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -Distribution box. 3. 1 -1000 gallon precast pit. Based on my Insrwction, I certify the following conditions: 1 . This is -a ,t,itle—five septic"system (: 78 Code ) 2 . -The eptic systems` �V. 'proper working ..-order, at the present time., SIGNATURE: Name:_J_P Macomber Jr... Company:J•P_MacoMber & Son-_Inc . , Cent_e�rville ,Mass__02.632 ` Phone: _SQ.&_375_333a...... _ - THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 3 � LS. P. MACOMBER & SON INC. gg� TankrCestpoolrleach(le1 d6 �J Pumped & lnsUllsd APR ections I. x 66 n Sewer enterClolenMA 02632.0066 775-3338 775-6412 U Commonwealth of Massachusetts V a a ZZR )L Executive Office of Environmental Affairs Department of Environmental Protection William F.Wald Trudy Coxe tior n,or se-"7 Arpeo Paul Cellucci avid B,Struha LL Gormor C*rninieworm e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddreas: 499 .Skunknett Road Centerville ,MAAddreast of Owner.Katie Doane Date of Inspection: 2/2 2/9 7 (If different) 3 Stuart Road Name of Inspector.. Joseph P.Macomber Jr. Gloucester,Mass . Company Name,Address and Telephone Number. 01 930 J . P.Macombe}r �& Son Inc . BCERT'IFICA7 s�IATEMENT Mass . 02632 508-775-3338 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate Lad complete as of the time of inspection. The inspection was performed based on my training Lad experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes T Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: �'" "�'"�t*' ' ' Date: '�X- 0ji- 5�/"' The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A. B, C, or D: 'Al^"STEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. Bl SYSTEM CONDITIONALLY PASSES: V d One or more system components used to be replaced or repaired. The eystem,upon completion of the replacement or repair,passes inspection. Indicate yea, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If*not determined*,explain why sot) The septic tank is metal, cra:ked,structurally unsound,shows substantial infiltration or extiltration,or tank failure is 1TMm;nnnt. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Wlnt•r Street • Boston,Massachusetts 02108 a FAX(617)SWI049 • Telephone(617)292-5500 i� Primed on Recycled Papa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t CERTIFICATION(continued) PropertyAddrees: 499 Skunknett Road Centerville ,Mass . Owner. Katie Doane Data of Inspection: 2/2 2/9 7 B)SYSTEM CONDITIONALLY PASSES (continued) dz( Sawage backup or breakout or huh static water level observed in the distrtbution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution boat. 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 inspection if(with approval of the Board of Health): broken pips(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH;- 4 d Conditions asist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public haahh,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: QLQ Cesspool or privy is within 60 feet of a surface water Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh 7) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINE9 THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 420 The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. �Id The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 60 fast of a private water suppb w4L Q� The system has a septic tank and aoil absorption system and is lase than 100 feet but 60 feet or more from a private water supply well,unlass a well water analysis for coliform bacteria and volatile organic compounds indicates that the wall is five from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm:. S) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddreaa: 499 Skunknett Road Centerville ,Mass . Owner. Katie Doane Date of Iwpeotlon:2/22/97 D) SYSTEM FAILS: • Al 1) I have determined that the system violater one or more of the following failure criteria u donned In 910 CUR 16.303. Tha basis for this determination is identified below. The Board of Health should be contacted to dstarmins what will be aeoessary to oorred tha tailor•. ,d�o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. 426 Discharge or ponding of effluent to the surface of chs ground or surface waters due to an overloaded or clogged SAS or ceupool. Z,p Static liquid level in ss 4irtribution box above outlet invert due to an overloaded or clogged SAS or cepool. ,q-�' Liquid depth in oesspooi•is less than 6"below invert or available volume is leas than L/2 day flow. Required pumping more than / times in the last year NOT due to clogged or obetructad pipe(#). 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. dX Any portion of a cesspool or privy is within a Zone I of a public well. tiff Any portion of a cesspool or privy u within 60 feet of a private water supply well. Any portion of a oerapool or privy L less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. 11 the well has been analysed to be acceptable, attach copy of well water aaa)psis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above, The system serves a facility with a derign flow of 10,000 or ter(gPd � Large System)and the system L a aignlScant threat to public health and"Isty and the environment because one or more of the following conditions cast: -h 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) The owner or operator of any such system shall bring the system and facility into full oompliaaa with the groundwater treatment program requimmanu of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for Authar information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 499 Skunknett Road Centerville ,Mass . Owner. Katie Doane Date of Insp"tion:2/2 2/9 7 ' Check if the following have been dons: iPumping information was requested of the owner,occupant, and Board of Health. �Noas of the system compoasq}ts have been pumped for at least two weeks and the eystam has been receiving normal Clow raw 7119 that period. Large volumes of water have aot been introduced into the system recently or as part of this inrpactina. As built plans have boon 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 now -- , The site was inspected for suns of breakout. ..L'.A11.system components,�itluding the Soli Absorption System, have been located on the site. septic tank manholes wort uncovered,opened, Lad the interior of the septic task was inspected for condition of baIDes or tsar,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 bean determined based on existing informatioa or ace tad dThe by non-intrusive methods. facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sul>. Surface Disposal System. (revised 11/03/95) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ~ PART C SYSTEM INFORMATION PropOrtyAddrv" 499 Skunknett - Road Centerville ,Mass . Owner. Katie Doane Date orIaspeotiow 2/22/97 FLOW CONDITIONS RESIDENTIAL Design flow: gallons PW64fty e Number of bedrooms: a Number of current residents:icy Garbage grinder(yes or no):,A , Laundry connected to (yes or no):�ay Seasonal use (yes or nos Water meter readings, if 0a — A7 AA Last date of occupancy:dA2L COMM ERCIAL/IND USTRLAL• Type of establishment:_A2A Design flow:,.AZd gallons/day Grease trap present: (yes or no).&j4 Industrial Waste Holding Tank present: (yea or no).A,2A Non-sanitary waste discharged to the Title 5 system: (yes or no)• t9 Water meter readings, if available:_ 4A Last date of occupancy: 42 OTHER.: (Describe) R Last date of occupancy: GENERAL INFORMATION PUMPING/JLECORDS pnd source of information: System pumped as part of inspection: (yes or no) 11 yes,volume pumped: One one Reason for pumping-. TYPE 0 YSTEM Septic tan.Vdistnbution box/soil absorption system Singls cesspool wJr7 Overaow owipool Privy Shared system (yes or no) (if yes, attach previous inspection records, if arty) Other(explain) APPROXIMATE AGE of all components, date inrtalled (if known) and source of information: '1XPE4t^S� _S� ?,I Sewage odors detected when arriving at the site: (yes or no)920 (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: 499 Skunknett Road Centerville ,Mass . Owner: Katie Doane Date of Inspection: 2, 22/97 SEPTIC TANK: Q11 '� J , (locate on site plan) Depth below grade: it, mnaterial of construction: concrete _metal _FRP _other(explain) Dimensions: �$ ' Sludge depth: • Distance from top of sl_tidge to bottom of outlet tee or baffle: CT_ 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. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle, depth of liquid level in relation to outlet invert, structural riry, evidence of leakage, etc.) Pump septic tank every 2-3years Inlet & outle Pumped septic tank astpart o in s ec ion. GREASE TRAP. -tJOA°U (locate on site plan) Depth below grade:- material of consirtwiion; _metal _FRP —other(explain) Dimensions Scum thickness.Zzlq, Distance from top cal scum to top of outlet tee or baA'le:A'�J Distance from bosom nt srum to honnm of outlet tee or oahle:Ajjj- Comments. (recommendation for pumping, cond-1-^n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural iniegray, evidence of leakage, et Grease trap is nor—present. (revised 0/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (ooatlnue•d) p�Pa 'Addroas: 499 Skunknett Road Centerville ,Mass . Owner. Katie Doane D&W of Iuipocuoa: 2/2 2/9 7 TIGHT OR HOLDING TANX:,?ivei (locals oa site plea) Depth below grada:-A matuial of coastrudloa: oona+ts_=.W_FRP_oth r(sxPWW - Capacity: 'VA pawns — Damn now rA1day Alum lawL• Commaata: (ooadittoa of inlet Us,condition of alarm and aoat switch", etc.) Tightor hoiing tank no present DISTRIBUTION BOXs_k"'� (locate cc site plea) Depth of liquid level above outlet Invert:_ Comments: I L equa), widens of lids carryover, evidaau of le-1-- into or out of box,etc.) Wo I' e x vaael: �ine : no evidence of solids carry over : No suns o leakage in or out of the distribution box.f PUMP CHAMBm-.&3Jle- (lochs oa site plan) Pumps is worldmi ordar:(ya or no) CommanL: (nuts condition of pump chambr,condition of pumps sad appurteaaaoa, etc.) Piimr) r+hamhar i G nnt, DrPSPnt (revised 11/03/95) � �• I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 499 Skunknett Road Centerville ,Mass . O„uer. Katie Doane Date of Iaspectioa:2/2 2/9 7 SOEL ABSORPTION SYSTEM(8Af/ Uocate oa site plan,if possibly;sscavation not required,but may be approximated by non•inb%wive methods) If not determined to be pressat,cryLda: e Type: �Z lewh;n chambers,number 1""), walla-W number. lis"llin namber,leagth: Lachia fields,numbsr, ns: overflow cesspool,number( Co—ats: (note condition of coil,sips of hydraulic failure level of poadia&con ditigp Qt y"got ation,90.) Medium Sand to coarsecsand: No Signs o22 h arau islai-Lure or nonding: All vegetation is normal. CESSPOOLS:N t/t✓ (locate an site plan) Number and configuration: xb4 Depth-top of liquid to inlet invert: 44 Depth of solid+layer Depth of so:m layer: Dimaasioas of cesspool: Material$of construction: Indication of mundwatar: inflow(cesspool must be pumped as part of inspection) esspoo s are not present Comments:(note condition of soil,signs of hydraulic failure,level of pcnding,condition of vegetation,etc.) uesspoul:6 ale not pest:-nt . PRIVY:,&�v e— (locate on aite plan) Materials of construction: NA Dimensions: NA Depth of solids:_N A Ccmmeata:(note condition of sad),signs of hydraulic failure, level of ponding,condition of vegetation,etc.) pi4- y net + Y� \ V (revised 11/03/95)• g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B SYSTEM INFORMATION continued " SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Centerville Osterville Marstons Mills Water Company 428-6691 1 \ �' �7, t � I / , L J DEPTH TO GROUNDWATER 16t depth to groundwater r+pth,od of determin ion or approximation: No w te.r encountered X�je-&.; sys tem, was installed r Co.vsrRVC -r-ioA/ .J� QPa//�oo7r7 u/� Qa th e-7 �/31-vi4 c z` J 7 Ti07-7 70 T He 0.4 / - ,d/ 14v- bz __ !�»el -/ pall,/l /V 7B `IP LIP9 �y.; Mr. Q r ti;jj: 3, 1 a t Ir ----- —i—' 74 -- ` —t— / hl f J _ �\ h I o, s �o v ; tlJ r � Bpi _i— CO PLAN! of LANDMa 9232 C ,FY ,LOCAT CAN 0 F THE AT THIS PLAN SHOWS THE ACTUAL 4#o su��� Irk C�.vrER vie k E MASS. .I TOWN OF Barnstable [BOARD OF 11EALT11 SUBSURFACE SFHA GF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I ��•TT'1T••••.'.�T.1,��.TTT1T r...',I,TIITIRlfT.f T1T.T!r�!'I T'tVT11�^P'�R11�� 7 T1, ..VT'P'^�• �..A -TYPO OR PRINT UEARLY- PROPERTY INSPECTED STREET ADDRESS 499 Skunknett Road Centervill,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Katie Doane PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Serl 'Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Strect Torn or City St•t• LIP COMPANY TELEPHONE ( 508 ) 775 3338 FAX ( 508 790 - 1 578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent With my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : XXXXXXXXXX System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public liealLh or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have c'onacted has found that the system fails to protect the j-)ublic health and the environment in, accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date 2/24/97 One copy of this ce tification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HEALTH. + If the inspection FAILED, the owner or""operator shall u d within one ,year of the date of the inspection, unless allowedort required he m otherwise as provided in 3.10 CHR 16 . 305 , partd .doc G V - Sbj1f 3r�1 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. ]unc 8. 1995 Acting Director of the ion of Water Pollution Control LO, ,A ON SEWAGE PERMIT NO• VILLA E ... I N S T AA Lj R' - NAME i ADDRESS BUILDER OR MILE. DATE PERMIT ISSUED , , �� DAT E COMPLIANCE ISSUED ..^i r `� a � 2 o� P....71 f .+-..:Job.k,. • .�No -•• ............... THE COMMONWEALTH OF-MASSACHUSETTS BOAR® OF H EALT�,, .7"................OF........,> 1'l`.7J S�GL------------� Apphratilan for lliipaual Works Tonstrur#iun Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System a .......kf� ............. Y --------------------------------- �1.;N?oy� Le .. - Owner ffess Installer Address q d Type of Building Size Lot_ �«� _._..Sq. fee V Dwelling—No. of Bedrooms.......... ...........................Expansion Attic Garbage Grinder (/� o 0-, 4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fi�xtu d W Design Flow_________________________________ __ gallons per perso�er dray. Total daily flow--___--_. .................... Ions. W Septic Tank—Liquid*capacity.A allons Length -.e.d..__. Width_..4.____._.._ Diameter................ Depth....... ..... x Disposal Trench—No_____________________ Width.................... Total Length............. Total leaching area....................sq. ft. Seepage Pit No-------/----------- Diameter-----0.......... Depth elow inlet____..��............ Total leaching area_ p.!___sq. ft. Z Other Distribution box (/) Dosing rto ( t3 n '-' Percolation Test Results Performed by../ P:?2 >~'_ _ 1! ���°�� 7� _.. •-• Date--_- a Test Pit No. 1.__. _.___minutes per inch Depth of st Pit_____ ____________ Depth to ground water___ . .:_a__._ . fi, Test Pit No. 2.................nil tes per i ch Depth 2of Test Pit. _. D th to ground water........................ o a-3' ------- -- : - Descriptionof Soil•----------------- �-=`--`-- -..... ? ------------------------------------------------------_.......... x W ------------------------------------------------•,------•-•-------•---•----•-••••••-----------••------••---------------•-•-----•••••-•-•-•-•-•-•••-------•-•-•-••..................................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi TIZ 5 of the State Sanitary Code—The unfjersigned further agrees not to place the system in operation until a Certificate of Compliance hJbissued y of health. Sig a .................•- - '-��•----•- - - ------- - - ate Application Approved BY `. ..... ........................ • Date Application Disapproved for the following reasons----------------•----•-------------...------------------•-----------------------••-----•-•-•--•••------------____ -------------------------••----------•--......-------------------•-----------------------•-----------------••-•-•-------•----•---•••---••--=---•--•--••-•-•-•------------------ --------------_--- --- Permit No.............. -- Issued - i.......Dau---'•' Date No.-79 r�• a ....1.3 ... Fps .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF I-IEA TH - ..7�to :?7...............OF....... Gs'✓ li 5 ..................................................e ApplirFa#ion for Dhipos al Works Tonstratrtion ramit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: J / r- Lo n-Address a -A Loty�� ....... 4.' .... ... - ___a _.. _, �L s Owner dd ss• - • r =-.. -•.............................•--•- Installer Address Type of Buildin Size Lot��`_j D.`.3......S fee Dwelling Building of Bedrooms.........SO..... .....................Expansion Attic (�`/ Garbage Grinder(AAU A4 Other—Type of Building,........................... No. of persons............................ Showers ( ) — Cafeteria ( ) a d Other fi tuffs •••--'•--••--•-•-•••-••-......•-•-••-••••••-•.....••-•--••-••------•-----•----•-•-•----•-- W Design Flow..•......................_ ...._....__gallons,per persor ) c�ay. Total daily flow........ _.._................_gallons. WSeptic Tank—Liquid capacity gallons Length __r`�...._ Width.. ........... Diameter................ Depth......! ...... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......I------------ Diameter.._. .......... Depth below inlet....._lk........... Total leaching area a.10 �....sq. ft. Z Other Distribution box (� ) Dosing tank Y �-- c �i ` ` Date ??0176 Percolation Test Results Performed b .. _..:.:. __ __......._. . W r , � . 14 Test Pit No. 1.....;,...___minutes per inch Depth of ,est Pit----l............. Depth to ground water.-��0....�..... Test Pit No. 2................winutesper inch Depth of T se t'Pit... :_.. ........Yepth to ground water........................ t '-----------•-------••-----•---------•----•-------------•---- O Description of Soil------------••.... G�-f, ca t ..---�--- -`s----- rni e.. - --- V ..--•---. .......................••-•------------•-•-----••-•---....--------.........-----.....------.....----------------------------------•----•----------------•-----------------.......-----•-•----•. W U Nature of Repairs or Alterations—Answer when applicable................................................................................._......._...._. ' Agreement: 'The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i IT1 I.. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by the o d of health. p Application Approved -L'w'...By". ty.r.... ....................... -` �...................... ....... Date Application Disapproved for the following reasons-------------•---------------•----------•---------------•---•-•------------------------------------............_ 1z ' Date PermitNo......................................................... Issued-`:....--•--•------------•-----`--••------------=------. Date THE COMMONWEALTH OF MASSACHUSETTS .. BOARD O HEALT ' �.........OF.......... ....... ........�.................. Tnrtifiratr of Toutpliunrr THI S TO CE IFY, That the Individual Sewage Disposal System constructed 'r) or Repaired ( ) by-"r--- •• . = •------- .. .......... .................•------. at... .. v ' - ------ G! Ins * ...........(Sehitary(Code ..-- ................. has been installed in accordance with the provisions o T 5 of The State as described in the application for Disposal Works Construction Permit i o _..:_...3- ................... . 'dated....i ."��." ................ . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS-A'GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................•-----•---•-•-..............................-----•---......... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . "' ..... 4 -4- 'j...............•--•-•------......... ............ .. 'lrC ... O F.... FEE-�-�./-•.............. ..e �t��u�ttl fur �un,��ttr�lun .eruti� eA_.... .......................................................................: :.........P is hereby granted... to Consm , Disp sal System Street n as shown on the application for Disposal Works Construction Perm' o.__---• . ...... ted.tl`._'���......................... Board:of ealth DATE................--=----------------•=---.._...-•-----•--•---•-••--• ............ " FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ., � .sh ��� » IV n nl� n /-�/l�� ,w/�� ��r�-, Jr, �� le 13 0�►-� o � �/e� f�r� .giu ;� f � �. s 7��. Wiz¢ t +. 73 p ,3 �/�Vp 7r7 t/r 7 Q ck- e J, z � mt , Sri y lv41r/r,Mc77 Yt��-L 4 '9 10-7-7 Sa x } ��- 14 17al .5/ .5 z ,2 77 i , 77 /C P- .77 e l4. Q 119 30 cp h� \' ! o v . 4 4 o© /1 41 t ° of G FRAM o"R Q PLAN of LAND I CERTIFY THAT THIS PLAN SHOWS HE ACTUAL LOCATION OF THE ��o svir? CeA1r,6R, t/!� � E. ASS. T ' STRUCTURE ON THE LAND AND 0wr m By THAT IT CONFORMS WITH THE A/ BY-LAWS OF THE TOWN � .� FRAI 19 F T K CO(VR 3 TRENM S T. 8�t 1 cY IYm1VPlIS, > . 2R1 lf0. ST T! 4 Q' � w tx*o eustvcv�e. c '�09��1 f TF►t��ik'�/ �18lfAL_��i`` SCALY- T t" -20FT- 8�7 T