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HomeMy WebLinkAbout0608 SKUNKNET ROAD - Health 608 SKUNKNET RD, CENTERVILLE A = 169 015 UPC 12534 ' No.2153LOR HASTINGS,MN I i & 99 9 '3-K'� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 608 SKUNKNET RD. CENTERVILLE MAP 169 PAR 015 L 15 Name of Owner MRS.CROWLEY Address of Owner: SAME Date of Inspection: 3/2/99 Name of Inspector:(Please Print)JOHN GRACI /am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02638 Telephone Number: (608)664-6813 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: kthe Date:3/3/99 The System Inspector shala copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. stem is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM NOW AND MAINTAINING EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE.THE DISTRIBUTION BOX AND FLOW DIFFUSERS HAD SOME SOLID CARRYOVER.RECOMMEND PUMPING BOTH COMPONENTS TO GET OUT ALL SOLIDS. revised 9/2/98 Page 1 of 11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 015 L 15 Owner: MRS.CROWLEY Date of Inspection:312/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. ND The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. NO Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced NQ The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction Is removed revised 9/2/98 Page 2 of 11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 016 L 16 Owner: MRS.CROWLEY Date of Inspection:3/2/99 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system'has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n[e_(approximation not valid). 3) OTHER n& revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 016 L 15 Owner: MRS.CROWLEY Date of Inspection:3/2/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n1a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,Is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 016 L 16 Owner: MRS.CROWLEY Date of Inspection:3/2/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping Information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was Inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 r n • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 015 L 15 Owner: MRS.CROWLEY Date of Inspection:3/2/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: 220. Number of current residents:2 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):JLQ Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): n/a Sump Pump(yes or no): NQ Last date of occupancy: n(a COM M ERCIAL/INDUSTRIAL Type of establishment: WA Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):JtQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n/a Last date of occupancy: n& OTHER: (Describe) nLa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: SYST M WAS AST PUMPED IN 1994 System pumped as part of inspection:(yes or no):NQ If yes,volume pumped n/a_ gallons Reason for pumping: n& TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date Installed(if known)and source of information: 19g2 Sewage odors detected when arriving at the site:(yes or no): MQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 016 L 16 Owner: MRS.CROWLEY Date of Inspection:3/2/99 BUILDING SEWER: (Locate on site plan) Depth below grade: V 6" Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nla Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ nfa Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: E Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: i4_ How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) „ SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY YEAR, GREASE TRAP: (locate on site plan) Depth below grade: ` Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) D& Dimensions: n& Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle:iVa Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) � I revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 609 SKUNKNET RD.CENTERVILLE MAP 169 PAR 016 L 16 Owner: MRS.CROWLEY Date of Inspection:3/2199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n(a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) D& Dimensions: nLa Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: NQ Alarm level:jil& Alarm in working order:Yes_No_ NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE IS SOLID CARRY OVER IN D-BOX, PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 016 L 15 Owner: MRS.CROWLEY Date of Inspection:312199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n1a Type: leaching pits,number: Wa leaching chambers,number: _2-FLOW DIFFUSERS leaching galleries,number: _u1a leaching trenches,number,length: n1a leaching fields,number,dimensions: Wa overflow cesspool,number: n1a Alternative system: n1a Name of Technology: -n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE FLOW DIFFUSERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROP RLY TH RE IS SOME SOLID CARRY OVER RECOMMEND PUMPING FLOWS. CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: n1A inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:n1a Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9098 Page 9 of 11 �r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 016 L 15 Owner: MRS.CROWLEY Date of Inspection:3/2/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a o 4A a4� as AC v j revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 608 SKUNKNET RD.CENTERVILLE MAP 169 PAR 016 L 16 Owner: MRS.CROWLEY Date of Inspection:3/2/99 NRCS Report name: nta Soil Type: nta Typical depth to groundwater: n& USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 LOT 15 Q 23,326 SQ. FT. ± CB/DH 0.54 ACRES ± ( FND) — p 887.23 PERIMETER N 77°S8,4 2� 1 .N 7 t � I0.17, C—, 27.46' 23.17' 14.20' o IP( FND) o BEHIND UP cU SHED N GAS � N 7g�48,02w ~ l ~ a 150,00, �Z V 2i , � _ 130,08, 99.98 ti Nr u") 34.84' PROPOSED �* 20' X 20' 3 S o S 78�*48.02 E' S �8 48,42, E 325 ADDITION ao o. ti 00 CB/DH 00-4 82 o < FND) N P 11O N cs Id o LOT 16 a CB/DH (FND) CERTIFIED PL0 T PLAN OF LAND IN CENTER VILLE, MASS. AS PREPARED FOR ADAM & SHANNON S ULLI VAN T0:ADAM & SHANNON SULLIVAN PLAN REFERENCE— PL.BK.339 PG.49p'`HOF��`�s�. ON THE BASIS OF MY KNOWLEDGE & (LOT 15) o`' PAU c INFORMATION, I FIND, THAT AS A E. RESULT OF A SURVEY MADE ON THE GROUND TO THE NORMAL STANDARD PLAN SCALE— U q N . 5044 N OF CARE OF PROFESSIONAL LAND 101=501 FFS5\��40. SURVEYORS PRACTICING IN THE 'fDS��yVE� COMMONWEALTH OF MASSACHUSETTS, DATE DRAWN— THE LOCATION OF DWELLING 12/17/17 IS AS SHOW REON. FILE: 2311-00 PAUL E. SWEETSER 12 17/17 vcg(41.. 4F.B.: EFB PROF. LAND SURVEYOR NOTES- P.O. BOX 1146 DATE PROFESSIONAL LAND SURVEYOR REV. DATE— DENNISPORT, MA 02639 LOCAT �ON � � SEWk` PERMIT N0. V1,� LAGE I N S T A LLER'S NAME i ADDRESS e UILDER OR WNER 5 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED } 1 �1r1/BEY f ell v � fvo3r l-Jr(7 I r. Commonwealth of Massachusetts . -W Title 5 Official Inspection Form . . Subsurface Sewage Disposal System Form Not for Voluntary Asses.'-"'ents 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 April 1, 2010 required for every —P 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. Important:When filling out forms A. General Information on the computer, use only the tab 1. . Inspector: key to move your cursor-do not Carmen E Shay use the return Name of Inspector key. Shay Environmental Services, Inc. lga Company Name 185 Ashumet Road _ Company Address Mashpee MA 02649 City/Town State Zip Code 508-539-7966 3080 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 oaf Title 5 (310 CMR 15.000). The system: , ® Passes ❑ Conditionally Passes ❑ Farls ❑ Needs Further Evaluation by the Local Approving Authority =_ i 4/1/10 Inspector's SignaCture -VtDate The system inspector shall submit a copy this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the/same or different conditions of use. I l.� 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewag Disposal System•Page 1 of 15 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 April 1, 2010 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments.- Opened Chamber cover and found 4" liquid at bottom of chamber. 8" effective depth remaining 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 Explain: ❑ 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 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form fSubsurface Sewage Disposal System Form - Not for Voluntary Assessments a 0'v o 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every. _P page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 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. 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every � _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h 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. 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10 9p 000 d. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 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. 608 Skunknett Road,Centerville.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 y Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is required for every Centerville MA 02649 April 1, 2010 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the.owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? E ❑ 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 CM 15.302(5)] 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every P page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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 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): 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every _ p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information 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: 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: 1996 - BOH permits Were sewage odors detected when arriving at the site? ❑ Yes ® No 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 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.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 24 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: 6' x 8' - 1000 gallon Sludge depth: 16" Distance from top of sludge to bottom of outlet tee or baffle 14" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition,lnlet Baffle in good condition, outlet tee in good condition - No significant scum or solids build up. 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.): 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): 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box Present 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.): Liquid equal with outlet inverts. One (1) outlet present. No evidence of solids carryover noted. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type.- El leaching pits number: ❑ leaching chambers number: ® leaching galleries number: (3 units) 1' x 13' x25' ❑ 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.): Opened cover to galley. 4" liquid noted in galley. 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 12 of 15 i Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.).- 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.): 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is Centerville MA 02649 Aril 1, 2010 required for every —p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 608 Skunknett Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 608 Skunknet Road Property Address Dawn Perreira Owner Owner's Name information is required for every Centerville MA 02649 April 1, 2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ®,,..Check.Slope . ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: No groundwater at 10' feet per hand auger 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: checked with GIS maps and hand auger. 608 Skunknett Road,Centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 IAPR. S.2010 9:59Af-1 BARNSTABLE BOARD OF HEALTH N0.794 P.J/J I k ESSQR'S MAP NO. gg �ARCEL--AM� , LOCATION 1=Y -- 1 -7f -z;k3 SEWAGE PtRIMIT NQ, V'ILLAG E UNSTA LLER'S NAME i ADDRESS i r� �e U I L D E R OR OWNER Le -DATE PIcRMiT 15SUED DATE COMPLIANCE I S 5 U E D Lai o rh . Ht'K. b.Gb1b `J:08HM BARNSTABLE BOARD OF HEALTH N0.793 P. 1i3 146�j2`)01`7 oy- 7Ht• COMMCNWFAL-TH OF MASSACHUSETT6 BOARD OF HEALTH Atwilratintt for Etep al w arks (9V1WU turn Permit Application is hereby msde for a Permit to Construct ] or Repair ( ) an Individual Sewage Disposal — •lv L��VaL•-�ltl.ri../ }....—_�.. ..... %✓.4�/.� r Lee Na ... ... Owe a ............. .�fr•W1.�::.� ..". ......___............... ..«..........T Addrtea .._.._,—_«r--..,«.........._, Ia,taRct Addrea •-7^7 Y—'•�'.___... Type of Buildutg Size Lot. ,i, `S�_...Sq. f Dwelling—No. of Bedrooms............ _.. ......__..._Facpansion Attic ( ) Garbage Grinds Ada. Other—Type of Building ................_....... N of person"................ .......... Showers ( ) —,Cafeteria ( ) Otherfixture-4 ..............._....._...----•-------.............._..--. ._ Deslga Flow...... ...., .� l..l....�.y.�-�None per P �"yr�Y. Total flow. ........... ..,... .. .. _o ... Septic X=k---Liquid captdty .gallons LenSt & (¢... Vtlidth.. _ Diameter...... Disposal Trench--No...._...............Width..._ ... __......Total Length.._ ».-t» •,Total leaching area:.. .. _._ s9 ft. Seepage Pit No...... Diameter.... ........_ Depth below inlet_._. 4,.„•, Total leaching atra�.�i.�sq,ft. x Other Distribution box ( ) Dosing Percolation Test Results Performed by.._._JC_ ,.. ( f � _« „ ,a Date ter c.. .l Test Pit No. 1......r.,,......minutes per inch Depth of Test Pit.,. :t Depth to ground w ter.... Test Pit No, 2.._.._..,.,.,nt4outes per inncch,1 Depth of Teat Pit................... depth to ground water,,,.__.......,.... ,••„ O Description of Soil.. -. u l .....-CLfi J" 1:_0. ................................................. ........---.............. aL ................................................................................. .....zq< �".'U-� Nature of Repairs or Alterations—Answer when applicable.__-----------....._._...................... ..............-.............._.._..._.. , ......................_.......................................r...............................................- Agreement: The undersigned agrees to install the sforedeseribed Indi idual Sewage Disposal System in accordance with the pro%isions of TIT2 5 of the State Sanitary —The dcrsizned further agrees not to place the System in operation until a Certificate of Compliance hag e o d of health. C �• Sign, n.�_... . . �1, ?�.. ��� Apphcataon Approved By--C"� .. =•• Y�!�,....... ...................._ _.)..� G �es,l,._.... X-_ • ,t pate Application Disapproved for the followiny,reasons:............... `} ...... .... _.._ .� y. ..._...._....-... ......._......................_.,.. ...........o ar......_.__ 1.4 Permit No. ..... I D L,. _..--•-••_- _. Data THE COMMONWEALTH,QF'MASSACHLi5FTT5 E30AR ,OF HEA1,TH b " THisgTD C,ItZY Y, That the Individual Sew ge disposal Systemdot>strveted h s been n Lolled i -.............Y. ««..__ a i s n accordance witli the provisions of TI10T r?of The State Sanitary Codes described in the application for Di-posal Works Constructinn Permit No.,..,_...:..`_..1„iz 1: :, .. datedr.....a.'J... :�.E? .............„ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU••N�N SATISFACTORY. •r••_ . 'y, ..........�._.,......�_..... � . ad ai ..o-,..�.Kl........_�......n_Y_.n ru..o.00:.n • t. ..._. , t.nrv�•.on� n..�ao ..........N♦..y un...u. a v _ tilt r.• ...Y:r�..�... ..� THIS COMMONWEALTH OF MASSAcHuaETTs 1 EIOARD W �AALT H � l �z OP,....., Permission is hereby granted .._tc..j, to Construct ( �)�or r ) an jndt duaI� ,e D�isp .1 ......................_»....._ ..... at No............... -•• -(• L � x',? c��f' /.«1�...._. _� . Sheet or Disposal Warhs.Construction Perntrt as shown on the application f 1 »a RATE...._._....Lz. 2... rrii.oiia....... ...... �.�a. ............. ..................... _ ... .. no��d e _...._. .. ...._ "-w',s-,;•. .•�-5.r-+r,,.�.. ,.._.....� „�._ ,.� .Ww'.'.'x�, ':+�;r-�4i-tea,:. .� __.__.._...._.__.....z:, .:u��� ""':�•-'" 'ate - - -^n.,, �' eoae.wa�sance®.�w.e^" O d fi �j s men eeewr .sea.. .er. w cXQ� 2'6 ,Q O � £ rn o � i I Al o � Z TOWN OF BARN LE S EX)c l Sp IAQE # ,VILLAGE l® ��yL ASSESS MAP &LOT 1 S ,)NSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER '1 ►�S PERMIT DATE: COVTL-bkN 60t�i Separation Distance Between the: 3 �Aq J 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 _ IA �� ay 40 I t A D 'l3 ° PA a6 L0iA '60N SEW �`CXP E R'IA I�T N0. ` G-0 T- J'// ten.l j l��T- 4''� VI LAGS v ,� INSTA LLER'S NAME i ADDRESS BUILDER OR MINER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �� �` ` f I n FE;..2.�....... ......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Kb!W=`----......OF......... .h..S. - ------------------------------------ A ,�pplirFation for Dispog al Workii Tontitrurtion ramit Ap lication is hereby made for a Permit to Construct ( 6l"or Repair ( ) an Individual Sewage Disposal System at: v o�a 5 ........._ ,... �,> ....--�----------------------------------------------- --------- �... L cation-Address or`Lo_t No. ��s Q er Address Installer Address elType of Building Size Lot_(Q3.3 �_......Sq. feet U Dwelling—No. of Bedrooms................ _Expansion Attic ( ) Garbage Grinder �+ aOther—Type of Building ____-_---•________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures -----------------------------------••-- - W Design Flow................. ....."Q.._.....gallons per person per day. Total daily flow........... ....................gallons. WSeptic Tank—Liquid capacity�n...0_.gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ) aPercolation Test Results Performed by________________ _. ......k.... ._ _.__._.....__._ Date.... __1 `...__..__. Test Pit No. 1................minutes per inch Depth of Test Pit._...._....._...._._ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil......... -------. s.) -----------------------------•--•-•------------------ U x�-. .*A..__..... ? Qsf1 ------- ( ------- •... ----------------------------------------4- ��........b�r_n. ------mat.d'..�------_------------------- ---\Q.-"--- �.�=--A..�?lc 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 LITI TLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed fY\Q ....... ----r '�' ''---•--....------••---- -•-�`� --°1-. -� 1 Da Application Approved By....... --•-•-.... -- ..... ....�® .-�� .--`�..-....... ...................................................•-- ate Application Disapproved r t e f o owing reasons-----------------------------•---------------........................ ----------•------------•----------•------- ---••-----------•---------•-----•-•--•--••----•--•- -----------•---•----•----------------•-••..0...................................................................................................... Date PermitNo......................................................... Issued....................................................... Date o...�.____. - F r ---- ss.............................. N y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` .. .. .. .........................OF......................................------....------....._.....---............._........ Appliration for Disposal Works Tonstrurtinn thrmit Application is hereby made for a Permit to Construct C ) or Repair ( ) an Individual Sewage Disposal System at: vs ....�...--•-•-•-•-------•-----••.....-----••-•-•-.....-•-•-•--•---•.....••................. Location-Address � CA r t No. n .. C... A dr ss.. ...................................... ner a \.evwx Lc'....•...• =................................ •--------------- n........ '...:...------------------------. --- ............. Installer Address UType of Building Size Lo��.�� '.-__.....Sq eet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder U) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures . - -••------ ----------•-----------••------------.._..--•-•-------•-------•------------- ^'' W Design Flow................ \\C) g P P P Y y .�, ..all ... �?________________ ____.gallons per person per da Total daily flow..__..._...._.___.__._.______..____._....__.gallons. WSeptic Tank—Liquid capacitp........gallons Length................ Width---------------- Diameter-_-____•---.-___ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_--_------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing to ) � ' '-' Percolation Test Results Performed by..._..__. -.-. tU` ......... Date-•----------------- 6011 7� �,~�\ _. -- •--------- •---- -----••-•-•---••-•--. Test Pit No. 1................minutes per inch Depth of Test Pit....._.............• Depth to ground water........................ 0�4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil....... ...................................................... -_�-....__1�c�:M_____ �(t �`-�� x :�\ C.�CUI.... e� �G�:&.........--- ---•----•--------------•-----•--------.--•-•-------•----- U �� --- x \ n c=l n --------------------•-------------•--------------------••----•••---------------- 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 TITS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. v Signed A, \... \ �-• i Application A PP roved B Y......._:_._" Date Application Disapproved f orh'e following reasons_ _______•-------•---------•---•------•--.................................................................. r Date `. gel .. ----•--•-------------•-----•-••--•-----••---•--------•---•-_............................... Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............:...................................................................... • �r�ifirtt#r of f�unt�linnrr THIS IS TO CERTIFY, That th Individual Sewage Disposal System constructed ( � or Repaired ( ) y.. == ...................... ...•....------......----------Im---- -----•------- ................;Z;......._.. ---- _. at........................ �.. \(-L -h has been installed in accordance with the provisions of T "L r o4 The State Sanitary e e ibed in the application for Disposal Works Construction Permit No ................. d-ated__..._.-__'.-.------ : ................. 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 ~.G r4 ` 3 ...........\..��..�.!�.............OF............ .L<4?>v.f1:�- .f, ........................ ' No.....:..............•.... FEE........................ Disposal Works Ton gudiott Prratit Permission is hereby granted----•------�.'J.e: ............. =u -----------------------•-----------•-•----.....---.......... x `' ' to Construct (e4 or Repair ( ) an Individual Sewage Disposal System r at No. - -----•----\ .•.............:`z.`4.Sa. ,?_C�.N.: _l . .. �r�.• ` streets as shown on thX�fpftca ' n for Disposal Works Construction`��e"tmi o.._.....V.....x...... Dated__._/....__.___(_/..................... Board of Health DATE...... --------- ---• ` •---•----•-•---•-------------••-•--........... FORM 1255 HOBBS & WARREN. INC.. 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H��� ====- f I i { f f NEW ( i "+ Cl� Irv. _ _ Ll G IZEAT i 1 0 0 N Room f I f---BEAMS I I (VAULTED I I g Q i f ( ABOVE i i CEILING)VFplIfY f i w/OWNER fi „ c j f CL ( f 4'-1 1 1J2" i I 4'-1 1 1/2 { I 5'-3 112" !; x EXi5T. S, - o Q LIVING EXIBT. tal ,.� I DININGEj ( i I I f f �.' ►-� UP N EXI5T. EXI5T. EX15T. EXIST. � w A C'6 ..� 0 2„ 0 ' 34'-4"± r---i (EXISTING) (ADDITION) Q �� d r T, f I T f L 0 O F LAIN' GENERAL NOTES: � � C'o �-� NOTE: I .) CONTRACTOR 15 TO VERIFY EXISTING CONDITIONS AND 5.) ANY DISCREPANCIES, ERRORS AND/OR OMISSIONS IN THE NOTES, THE PLAN5 SHOWN ARE LEGEND DIMENSIONS IN THE FIELD PRIOR.TO THE START OF WORK DIMENSIONS, AND/OR DRAWINGS CONTAINED ON THESE DOCUMENTS THE 50LE PROPERTY Of 2.) CONTRACTOR TO REMOVE EXISTING DOORS, WINDOWS, SHALL BE BROUGHT TO THE ATTENTION OF THE DESIGNER PRIOR TO THE DE5IGNER AND CAN EXISTING WALL CONSTRUCTION TO REMAIN NOT 13E COPIED. WALLS, * ROOFING AS REQUIRED FOR NEW CONSTRUCTION. COMMENCEMENT OF CONSTRUCTION. PROCEEDING WITH CONSTRUCTION REPRODUCED AND/OR NEW WALL CONSTRUCTION 3.) ALL NEW CONSTRUCTION TO MATCH EXISTING IN MATERIAL, CONSTITUTES ACCEPTANCE OF THESE DOCUMENTS AND ANY DISCREPANCIES ALTERED WITHOUT THE C=� EXISTING WALL CONSTRUCTION TO BE REMOVED ERRORS AND/OR OMISSIONS BECOME THE RESPONSIBILITY OF THE ffcPRE55 WRITTEN DETAIL; AND FINISH. BUILDING CONTRACTOR.. CONSENT Of THE NEW/ EXIST. 5MOKE/CARBON MONOXIDE DETECTORS 4.) ALL WORK SHALL CONFORM TO THE MA55ACHU5ET15 DESIGNER STATE BUILDING CODE (LATEST EDITION) AND ALL OTHER SCALE : APPLICABLE LOCAL CODES 1/4 1 0 WINDOW CH EDU L r fl t DATE : 2/14/2018 TYPE MANUFACTURER'S UNIT ROUGH OPENING REMARKS v `PROJ. NO. A MARVIN INTEGRITY ITDH 3048 2'—G 1/2" x 4'-0 114" DOUBLEHUNG _ B if ITDH 32GO 2'-8 1/2" 2017-8012 x 5'-0 1/4, DOUBLEHUNG ,. CIt IRT3G-2W DH G'-0" x 3'-0" HALF ROUND STAMP: DWG. NO.: D If If LAWN 2523 2'- 1 " x I '- 1 15/8" AWNING NOTE #I :CONTRACTOR TO VERIFY ALL QUANTITIES AND SIZES OF NEW WINDOWS WITH OWNER AND ROUGH OPENINGS WITH WINDOW MANUFACTURER PRIOR TO ORDERING OF WINDOWS 0 5 I 0 15 20 C COPYRIGHT 2018 NOTE #2: CONTRACTOR TO CONTACT PAM DIVENUTI AT MID—CAPE HOME CENTERS (774-21 2—GD58) �BY THOMAS A. MOORE DESIGN CO. TO REVIEW WINDOW SCHEDULE AND_DETAILS Of WINDOWS. 00 LO o ----NEW ROOF SHINGLES 0 TO MATCH EXISTING --- LJ NEW FASCIA 4 FRIEZE BOARDS CYD CEILING HEIGHT TO MATCH EXISTING U � CD 1L1Lti_1�11" r-__-_-___ i � 0 f !111.l , i II L E1300 1L�� I LI Ul Ill x d I IL(�J1J1�L1L I llLW i I i > �" { ll1 _L.C11111 1 1 I ' 4 WINDOW ED-OUT J.11llLl1 1 i _ b~ it l C LL_u_ILI L 1LLllLIW LLI' I ` I C FIR5T FLOOR lLiLll(I U II LI it 5UBFLOOR _ 1J. 11Ti it 11 1 i II_L I ll_11 l i li f!f i I II ! Ll_1LI) � 1I 3 f II Ii (I I II iI f ( ; 11 i NEW CORNER BOARDS ` I i 1 I TO MATCH EXI5TI NG Q N W NEW WHITE CEDAR f ONO M T E LE V AT I ON SHINGLE 15TIN TO MATCH EXISTING L.ia � c) � 34'-411± 20'-0 . . (EXI5TING) (ADDITION) =' Q ~ A ►�-� �XIST� FE­CIST� ISKI LT.I E EX15T. ISKI LTA > EBATHI T. BATH --g— _ s ou06 EXIST. I > BEDROOM Q �F�cIST-1 Ex15T. NEW W LSKI EXIST. Q GREAT DOOM }, EXI5T. HALL BELOW z00 DN - - - - - Fi- B o Q O d NOTE: THE PLANS 5HOWN ARE EXITF i . . ": THE SOLE PROPERTY OF MASTER T,� s�` _ . THE DESIGNER AND CAN �� �.-°' .." � NOT BE COPPED, 4. 1 REPRODUCED AND/OR 1 BEDROOM U �' � . ALTERED WITHOUT THE EXIST o �_ cI ` s NT©FIEEl T o WRITTEN BEDROOM DE5IGNER SCALE 1/41, _ 1,_Q„ f DATE : N 2/1.4/2018 N A PROD. NO. As 34'-4"1 20'--0" 2017-80 12 (EXISTING) (ADDITION) STAMP: DWG. NO.: SECOND f LOOK PLAN (JS NEW/ EXIST. SMOKE/CARBON MONOXIDE DETECTORS 0 5 10 15 20 CDCOPYRIGHT 2018 BY THOMAS A. MOORE DESIGN CO.