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HomeMy WebLinkAbout0644 SKUNKNET ROAD - Health 644 Skunknet Road Gente_rville A- 169-015 - 021 n o ° 6 Pendafle< a Esselte 4210113 ORA 10% P4 I u � ay V (l O 7 ap 0 I 0 _ 5 , i V I FIB$....... . ............ THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH ................OF.......... .�n..S.V .` `"✓ ...-_:.. Y. �S ApplirFation for BiupuuFai Works Tomitrurtiun Errant Application is hereby made for a Permit to Construct (X4 or Repair ( ) an Individual Sewage Disposal System at: eolc...... ._ .. .............. - ......... Location-Addres or Lot N . .._... �A.L!� 5.......- ` ......... -fh-� ^............. � 1.�n.. :? ................................ - ..... -- Own Addres .............`!.. ®. �.!�—v..----•---.`.�1..)..: _.�.._.................... -----....... -S ...----------------------------------------- Installer . .....__. p� Address Q Type of Building z Size Lo ......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder a'4 Other—T e of Building ___ No. of YP g ------•-•-•-------------- persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------•------------------------------------------•••••-••••••--•••--••-•- W Design Flow...........*$A\.Q......................gallons per person per day. Total daily flow................__......_....................gallons. WSeptic Tank—Liquid'capacitA0.00gallons Length................ Width................ Diameter................ Depth................ 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 k ( ) Percolation Test Results Performed by........ __�C.A ..___�'_. -..... Date..... ' ',:-5 -�...... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------•---- -••---•-•--•••--•-•-•-••••--••-••......_..-••-•.............•-••-•...-•----•........•-•-•-----••-••-•-••••---••--•--•-•-•••---...-•-• Descriptionof Soil...... .._.. ....._ . •--••-••- S`----NA....................................................................... \ 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 iITLL 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......... &.Y�l o -----• ' ........ g'� ��� -------- Date Application Approved B _ =1. .. ........................ y,/ -------•--- Date--------.... Application Disapproved for the following reasons:_________________ -----------------------------•-•---------.....-------------•------------.....------•-----------•--------•---••---•-••-•----•••••-••-----•-••------•-•--••------•-•-.................................... Date PermitNo......................................................... Issued_....................................................... Date 9_4 ................. THE COMMONWEALTH OF MASSACHUSETTS _ BOAR® OF HEALTH ..... 01_0 0..............OF.........\:�.c.,\n - C�..., V DU— .......................................•----•-••-----•--•-----....•. Appliratiun for 31ispos al Works Toustrnrtiun ermit Application is hereby made for a Permit to Construct (t.4 or Repair ( ) an Individual Sewage Disposal System at ......... .................................................. --•-•-• = .....------- ........................................................... Location-Address �-� or Lot No. - -- - ......... . ...... .........•--•• .......................................................� Owner Address Installer Address Type of Building Size Lot.` ....... ... _.._._Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (pep aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures . - - - -- ----------------------------....................................................... W Design Flow............\&O.....................gallons per person per day. Total daily flow.......... . ...................gallons. WSeptic Tank—Liquid capacity`s t Ugallons 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 ( ) ~' Percolation Test Results Performed by.--__-__a��s '.��_._r'� ^.__.. ":__.l�` -A,'-:=..... Date...... ...��.'.-._. .. \...... �] Test Pit No. I................minutes per inch Depth of Test Pit............_.......//Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ -Description of of Soil. ^:�.- �, .) c.�r--�. �---,-- ` -------- ------- 0 - ....... --- • •-- �'j - \ -.�_ vMc- A. CCI n- ------ •------------------•----......... • --------•---------------------•...--•-----...------......---•--•---- V 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 TITT-2 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----• C�/1 \U �J-`�� _l` , _ "-- -....-- ----- •-------- Application Approved By..................=-`' '- %_:.... '' ��......_............ `• •`t/ Date Application Disapproved for the following reasons:................................................................................................................ Date PermitNo................................................... Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ................................................ IT Tntifirate of ToutpliFanre THIS IS TO CERTIFY, That,the Individual Sewage Disposal System constructed ( t-)or Repaired ( ) by - 0. .. -\ �C: r, ----------•. ...... . _: -- - =---------------------•---•----------•--••-•-•-----•--•------•-•-•-----.........................---- Installer n has been installed in accordance with the provisions of TIT=-E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---Z���___._V_S_/.._.__.._._. dated__................... . ----------•-•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIONS TISFA TORY. DATE. / / 1 Inspector.. . i ......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t_. . r,��rs ...... ,.. ............OF.............�.. :�----..�:...�.::---=--�: ..... No.... ':............l�•- FEE...... .v.... -- �i��u��tl urk� �un��riun hermit Permission is hereby granted......... Q:: -c�. ..................................................... •.........................•-••-•-...........---....... to Construct ( L,- or Repair ( ) an Individual Sewage Disposal System at No....................... f ../.... /!---::.. == ....f' C'.._.//%✓%f- ....---•---••••--•••--......--•........ Street as shown on the application for Disposal Works Construction Permit No..................... DD red.._.._._....___........................... Board of Health DATE------------------•---.....------....-----------••--•-•----•-----...---..._._... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L O CA T 10N � S El W -E--P._ RMIT N0. Lo VILLAGE INSTALLER'S NAME i ADDRESS L/ r�/9t/-® 6k 5 8%oa e UILDER OR OWNER DATE PERMIT ISSUED DATE C 0 M P L I A N C E ISSUED �61 LA i „ .� S��Ym try �'Mnl Lam! - 3 3��oai` '� •�+'� 1 Del�� Low m 110 3 + SSO 6-P.M �EfgrlC 'T A"v- r- sso, ISO uS�- t Ooo 6A L-. 1'?15Po5,Di_ PlT - uss✓ l oo� GAL. f 150 SF 2.S 9 3'7S e�.P.V. P,T 4B•4 \ 9 ' To-rA L -C>ESIG►.1 = d2S &-.P.n. TbToL:. hall 1..�{ Fc�w = 33D 6;P.D. o•max Grp. \ �f1GDl.bTl06.1 CZ®Tar : `�� s n� cr C L-7 CV q t AL 41 1 4YAX7 fl ° U Ja f �} �.��w�p " ' �' "I TrtM7o RY' ..rid'_.�G� _ C / �° , • �dtio f anal f,i cum De- s^� , l / O ' slwlJ' Tor P'un s tao.o�.. L o,a rn ape I IUV. '.A :i r$JgSp�L fl, lW- L�AL. 94•S 'BOX 9$•G sEpncloco .V.0 5.� LPN ©AIT _ Fps SAAJZ ''.' - . - C�t;.Tt'�1ED F1-dT' t='L.�•1`,i �IQpF'1LI= L;OCAT1o" WTEV�/1c._c.Z ;Cl�l_ l�o /�rrL. I �►� RLF r,EticC :' GGizTi'F�( Td-Wr T14a F0uND&<<ot4 5�lawd.➢6-aF.�'L••Od_1 Gc�t�PL�IS fit/IT14 TWG LoT C h .I :. AWC), Sc - -,.ACV r64 1 o w►j 0 C.3 NJ?.�s-T A-,16 L . rix-re 7 �119 L13a)CTEbZ. b1`(� lac. ' � ,: 6ZEGl5•ttt;ED L.A6.1G 5U2v`K��`• 05TEZV%l+tt. o j. MA5,5,. r ` 1441 cwAAE �.1; �,Ut_�It_�( � Yt{G: U � , �i+1Ga�uD Ab�P!_.lGAtiIT � :; ►•..bar �,r u�aGr, r� I�ere�a�►��; LOT LIW .•-'a y J awlae, (� 5yd AsBuilt Page 1 of 1 -- Ac LOCATION f7SEIW"GE---PERMIT NO. VILLAGE L//L L�g INSTA LLER'S NAME i ADDRESS U I L D E R OR OWNER DATE PERMIT ISSUED 1 DATE COMPLIANCE ISSUED Loi http://issgl2/intranet/propdata/prebuilt.aspx?mappar=169015021&seq=2 8/12/2015 Commonwealth of Massachusetts see co�M, s - Title 5 Official Inspection Form Subsurface Sewage Disposal y is osal System Form - Not for Voluntary Assessments t, Property Address nor Av ner's Name ?inf a n infom-ation is / Q� �/'�j� �� J required for every City/T page. own State Zip Code Date of In pection 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, Ymportorr s A. General Information filling outut f forms I � on the corrputer, use only the tab 1 Inspector: key to move your / ✓� cursor-do not a Y- 0 use the return Narre of Inspector r —� / 6 C key. G/—` lV/ I 1/1 Company Name d- 'Y F Company Address ream Gt S City/Tow n State q0 Zip Code Telephone er license Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5 (310 R 16.000). The system: LL1 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Hoard 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 gpo 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. t5irts•373 Title 5officiN IrspectimFrxm,Subsurface Sewageoisposal System•Pago t or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a - b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner ON ner's Name / information is Ceram 4V V-/11'e required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) S7ystem P sses: 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: T7oc4se_ lye C 00IL? S © 1 14 Ie(_J rvo-,17S , re Id Ca l o e7 0;1/- &MS2�44 Q2- B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltratlon 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). tbim•3/13 'riUe 5orficial irupectico Form Sutnuiace Sewage Disposal System•Pago 2or 17 Commonwealth of Massachusetts w _ = Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cw ner O+v ner's Name information is 0. V,t'6 required for every page. Gtyffown State Lip Code Date of spectio B. Certification (cons.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): 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 mannerwhich 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 t5ir>s 303 Tito 5UfficA ImpecWnFam subsurface Sewage Disposal System No 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System F//orrm - Not for voluntary Assessments Property Address ON ner Cw ner's Name ceo-1�11T-a information isrequired for every page. City/Town State Zip Code Date 90rispectlon B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 ❑ M'! 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 t5ir>s 3113 Title 501ficiar.lnspectionFam Subsurface Sewage Disposal System•Page 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for voluntary Assessments � ��j 2� Property Address ,7 ON ner Ow ner's Name /'eN ✓v` �A ! ?� inforrrration is l/ � Ile �,/Q, 10 J A'V rpe ge. for every City rrown State Zip Code Date of Ins ection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or / obstructed pipe(s). Number of times pumped: . ❑ L'� 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. ❑ QJ 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. (Phis 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.) f/ The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ 10,00 Og pd. ❑ 9 The system af�ii . 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 annking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes' to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department. tans•3/13 Ti do 5Official Ins poctim F orm Sut)strtace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 14c,11 / Cw ner Cw ner's Name information is y► 1�� a required for every Ce d- O page. CitylTown State Zip Code Date of In ection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes u��.were mping information was provided by the owner, occupant, or Board of Health ❑ an of y the system components pumped out In the previous two weeks? El ff" /Flas 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? L� f 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: Q= 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)j D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): all t5ins-y13 Tiuo5Official Ins pocUaiForm.Sutsirfnca SewegeDisposal Syslem7Pa{a"ro117 i Commonwealth of Massachusetts Title 5 Official Inspection Form h o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 JP Property Address ON ner ON ner's Name / 1 information is Ce0.kt/(/�` required for every page. City ffown State Zip Code Date of Ins ection D. System Information Description: (/) G ` µ Number of current residents: -� Does residence have a garbage grinder? ❑ Yes 2---No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 9 No/ information in this report.) "e- Laundry system inspected? ❑ Yes [ Now Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ea r y ❑ Yes KV-'No Last date of occupancy: �,��� p Y ( alb eWS _ Date Commercial/Industrial Flow Conditions: Type of Establishment: -- Design flow(based on 310 CM R 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: - l5ns•N13 1 We 50ffidal ins pectlon Form Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts w Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments co vl� Property Address ,,/o ON ner Cw ner's Name / p information is / eNv� fJ A4 required for every t� page. City/Town State Zip Code Date of Ifispection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ` Source of information: Was system pumped as part of the inspection? ❑ Yes E— 0 If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ns-3113 Title 5Official InspecGrn Form Subsurface Sewage Disposal SySlem•Pape 8of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form a b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Property Address G // ON ner Cw ner's Name Ce �/finformation is _ 4�IV7'114 /%� 06 � arequired for every ;)A, page. City/Town State Zip Code Date of In action D. System Information (cont.) Approximate age of all components, date installed (if k own) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes EJ__No Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron n 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material 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: Sludge depth: t5ins•N13 Title 5 of ncia iru pec tion Formy Suosvxf ace Sewage oisposal System•Page 9 of 17 Commonwealth of Massachusetts = r Title 5 official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address owner owner's Name J_ information is Ce v,-t�✓(/l / ��6��.. � v�-� � _ required for every page. C+tyRown State Zip Code Date of I spectio D. System Information (cost.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle /le How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): / a. /,, G 0./ 7�S 1,17 o Co., G l7?0✓I i 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 t51re 3113 Title5O0cial tnspecticmFcxm Subsurface Sewage Disposal System.Page 10 cf 17 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / �I Ow ner Ow ner's Name / �ry information is CeN,•v41j /� 0,16 Z2 JP 1P required for every "— page WTown State Zip Code Date of Insp ction D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Matedal of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5im-3/13 TiUe50fficial IrspecticnForm:Subsuiace Sewage0isposel System-Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form A - Subsurface Sewage Disposal System Form Not /for Voluntary Assessments Property Address / ner pa ner's Name inf A4 �G��- -e �� / information Is / �,N, required for every l/ — page. Cityrrown State Zip Code Date of nspecti n D. System Information (cont.) Distribution Box (if present 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.): X1v Sol�s 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 19M-3113 TIUo5Officlal InspectionForm Subsurface Sewage Disposei System•page 12cf 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w °� Property Address q Ow ner Oro ner's Name information is �Qv�.>�✓�/( �/ ( (, �� �__ required for every State Zip Code Date of In ectiory page. Qt —ffown D. System Information (cont.) Type: i 6 ) 1 -S�, leaching pits / number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Z '.0V �o -14o o Si ✓:s o� !� /i�;'wxC 1 114 A- 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 t5ins•3/13 TMe5OfficiN Im pec don F orm.Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Property Address a Cw ner ON ner's Name information is required for every e►, page. Cityfrown State Zip Code Date of 1p4pection � ` D. System Information (cont.) 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.): lSns•y13 Title5Official InbpmfienForm SubsuNace Sewage Disposal Syslem•Page 14 0 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Aol ON ner ON ner's Name information is r 0'�L 3� required for every —-- page. City/Town State Zip Code Date of rnspectioA D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where tic water supply enters the building, Check one of the boxes below: hand-sketch in the area below ❑ drawing a tached separately lool J�- 11 3 - t5ins 3(13 Title 5Official If%$rwlial F Orin:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / Cw ner Ow ner's Name Ce information is ��v,14 /�required for every cT� page. City/Town State Zip Code Date of nspecti n D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: 0 J- t i Z J4 /40% ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ru-3/13 Title 5 Official ImW,tionForm:Subsurface Sewageoisposal System-Pape 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form J s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / 1, Owner Owner's Name CQN c/` //(� information Is / required for every page. City/Tow,n State Zip Code Date of nspecti n E. Report Completeness Checklist LEI Inspection Summary: A, B, C, D, or E checked Er (Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Ly' System Information— Estimated depth to high groundwater D/Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15iru-3/13 Title 5official IMpectian Form Subsurface sewage Disposal System•page 17 of 17 l,p CAT ION S E W A G E PE-RMIT N0. VILLAGE INSTA LLER'S NAME i ADDRESS C40,OvSr /14 rr-ah/e e U I L D E R OR OWNER �G,�eL - SoLLewr _ DATE PERMIT ISSUED p-aa R DATE COMPLIANCE ISSUED c .rb� �.R0. AV-EA �50 i�� SF ,c 2•S 9 3'?S C�.R'D. P,T \ r �p Sri, x t •� �' SO �•r•V, T. TOTAL 'bESi6Q .425 .. i fZGDl.dT10tJ QATE ; CIQ 1-ml► , o4Z L4s. q- s s qq. `U L -7 ..,.�,; „A •��,N of ,�;;`� N � v 7EMPoRAR AID / \ r S ty :6.a 41 27, 4'-PPS �. Iw. LaAL. Z -Box 46, G s(%a9nC �z�i�, GAS. 9G,Z ��'4 �• S PIT ia aA ' F SNP w/IT%-t SToui= q U,n LE,ZTtT=1ED 'PLC)7- F-l-L.A,�-...1 /2 F G. 0 1.J o SG ALA �-�C A L t~ 111= i L- - GGiZTtF�( TWAT TNT 1-ouNt)A,TIoN Su m cCOAP wtTt� TN, A.blt� SE'1'�AGk �:C-QUt�E�c�T� C� T1-aC FL u�C- tic. l CZt~L t S'I-C=PAD '1-•A!-�G SU:_�1�`f o::: 'e t-�l5 C7Lla1 S 4'S L-!OT �;oSEb ��� A6-1 i lk�'�Di['UME:"w 7 `�JG /L { • Tttt UK�; Cr, �t.1Gi:1lD Appt_l y P DOI d FRONT ELEVATION SCALE: 1/4" = V-0" � I LL Z LU O ® ® � ZW 91 0 cpZ w w � U R�T V 544EET I OF 4 -:REAR ELEVATION l SCALE. I/4 = I 0 A V 5- 1514 AWN 5Y.NW TE- . g25/15 i V a I I ReIOVEDOOR OiOR I I AND I IINFILL I I W RIGHT ELEVATION SCALE: 1/4" = 1'-0" L J L_J 0 Q W w _J LLI W N W W ® � U �9 SHEET 2 OF 4 LEFT ELEVATION L_J SCALE: 1/4" JOB" 1514 DRAWN BY- HN DATE. q/25/15 I. 1 •. II'-6 1/2" j 34'-0" p 34'-0" 2'-0" 7'-q 1/2" 7'-1 1/2" 5'—q" 6'-0" 5'-4" 21'-6" 2'-2" 10'-4 1/2" 'i 15'-7" 5'-II" cr �p 6. fn _On p 1 I -- - -d KKITCHEN _ — q II 7 3/4 c 7 1Oil 14 6 I/4 0 OJ 5K'f BATH L= oT 1 LIGHT 24310 p EXISTING WINDOW fl - M /� ISLANDOle I is- ---- 2 iv��4 i PLAG ENT 2 c) t \ — _ B" _ ------- 3'_On ._bn--- 3._6n MASTER SUITE 5 4 ISTI WINDOW EXISTING WINDOW df _5i N P C ENT (V PLACEMENTZ 3 � -2 I/ 2� 2 2 - 10'-2 1/4" II'-7 1/2" 2 12'-2 1/4" I� a0 0 0 2 �i NEW BEAM ABOVE ----_ I) 4'x4' POSTa m �n BEDROOM #2AJk ON DN BEDROOM #3 Ln s 'v N1 1 22 5 _-_-__-_-_- EACH END N r m EXISTINGN INDOW (V LI k 2 PLACEMENi16'-0 1/2" 3 I4'-6 1/4° ISTING WINDOW 2Q LACEMENT -- EE 24310 EXISTING WINDOW \ ❑ pi PLACEMENT m Q STUDY 10 LIVING ROOM Q uP N '-2' W -Z _ _ _ _ - -------- w W o n C� N Z O W Lt 5'-0" 6'-2" 6'-8" q'-0" 7'-2" 34'-0° ^ 34i_0n `NV s FI RST FLOOR PLAN SECOND FLOOR PLAN SHEET 3 OF 4 SCALE: 1/4" = 1'-0" SCALE: 1/4" = 1'-0" • JOB. 1514 DRAWN BY. HW DATE. q/25/15 I6:_On i A JOIST HANGERS EACH END - - - - - -I 2) P.T. 2.10 GIRDER bx6 P.T. POST GALV. METAL POST ANCHOR 10' 'SONO TUBE" PIER W/ r-------I 28" "BIG FOOT' FOOTING TYP. __ DBL RIM JOIST . F —I I 1 8e I I I I 0 16 O.G. BULKHEAD6 BILCA //nn ( DOOR I TO RIM JOI ST (22)) 6 PT 2x8 ERWIITO8" U IB EXT.. I I GALV. LAG BOLTS Ib O.G. -------------- ---------------------- 6� Q I 20 no r EXISTING e EXISTING S La N m BASEMENT I I I 14'-2 1/2" I IUdbbbbU EXISTING 2x8s k2E1 LVL BEAM P(LACES"REMOVED WALL I ______ o f ' ■/�■ EXISTING GIRT �------ �����------_ I cc ` I "p EXISTING ADD 3 1/2" DIA. STD LALLY COLUMN W/ 1 30"X30'XI2' FOOTING i �` FIRST FLOOR I I ALIGN WITH END OF BEAM ABOVE NEW 0 L J DECK Z EXISTING 2x&s Q PT 2x8s Alf EXISTING GIRT - I 3 1/2' LALLY COLUMN wEXISTING . I � -------- s _ __ J F BASEMENT ( 1 LLj ----- ---�-- ----- _ \ L J v w J ———————————————— ———-— :. 0- Z IL 30n N (f) Z O w { 24'-0" U 0 34'-0" Z u- € FOUNDATION PLAN 1 SHEET 4 OF 4 SCALE: 1/4" 1'-0" 9ATE: 9,/1125/15