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Home My WebLink About0158 STONEY CLIFF ROAD - Health 158 Stoney Cliff Rd..Centerville f No. 42101/3 ORA ESSELTE 10% 0 0 0 0 I w • IUD-03a- Commonwealth of Massachusetts - Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville t✓ Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:out forms A. Inspector Information filling out forms on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. P.O.Box 151 Company Address Forestdale Ma 02644 City/Town State Zip Code reuan 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4/13/2021 Inspector's Sig ure Date The system inspector shall sub :c:o p)thesystern is inspection report to the.Approving Authority (Board of Health or DEP)within 30 d s om this inspection. If the system has a design flow of 10,000 gpd or greater, the in ect owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems . Information on care and do's and don't's can be found at town health dept or mass. ov 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal. to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the.previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is Centerville Ma 02632 4/13/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 549 pit Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: leach pit 6'x6' Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: gimped during inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2000 gallons How was quantity pumped determined? truck gauge Reason for pumping: cesspool regulations t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts 1 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: cesspools original to house leach pit 1989 per asbuilt Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): good flow to cesspool t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,w 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1" a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 2 ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection D. System. Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leach pit cover#3 had 6"of water in bottom clean sidewalls 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 see asbuilt Depth—top of liquid to inlet invert 2" Depth of solids layer 8" Depth of scum layer 1" Dimensions of cesspool 6'x8' Materials of construction block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): cesspool#1 and number#both full to outlet levels. reserve is in leach pit t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts h Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts r� (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � U CQSsP:) � —� 0 01 5 2, �-!1 L 62 - 3 I t 7� P� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Epperly Owner Owners Name information is required for every Centerville Ma 02632 4/13/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: town GIS mapping You must describe how you established the high ground water elevation: lot el. 48' per mapping low wetlands in area within 4 house lots el. 28' bottom of leach pit lowest of all components el. 38' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �m = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w � 158 Stoney Cliff Road Property Address Epperly Owner Owner's Name information is required for every Centerville Ma 02632 4/13/2021 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse Owner Owner's Name Information is Centerville Ma 02632 4/1/2013 required for every -- --- page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:when A. General Information filling out fortes on the computer, use only the tab 1 InSDBCtQf key to move your �..\) • `� cursor-do not Bernard J Lynch use the return Name of Inspector --- -- key. MA Cape Cod Home inspection Co.VQ Company Name 34 Milton Hill Road Company Address Milton - MA 02186 Cityrrown State Zip Code 617-997-3769 S1142 Telephone Number License Number T 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 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evalua=b,the Lccal Approvingi Ailtherity _ _ 4/1/2013 l Inspector's Signatur Date i The system inspector shall Jbmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ""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. ISns• vt 0 TO&5 Ofrcw fnspecom Form suomwam sexege asmsm system.Page 1 or 17 � `� I(� I 7 Ultu V r Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road _ — Property Address Carole Morse Owner owner's Name information is Centerville _ Ma 02632 4/1/2013 required for every CityJTown State Zip Code Date of Inspection page. B. Certification (cost.) Inspection Summary. Check A,B,C,D or E/always complete all of Section D A) System Passes: i have not found any,information which indicates that any of the failure criteria described in 310 CMR 15:303 or in 310'CMR 15.304 exist. An fat ILre criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 efittration 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. e 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): t5ms-11110 Title 6 Of6pat tnSpection form'SubsuMoee Sewage 0400sat System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse Owner Owner's Name information is Centerville Ma 02632 — 4/1/2013 _ required for every Stale Zip Code Date of Inspedion page. City/Town B. Certification (cont.) 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 ❑ NO(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 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 u-ns•11110 Tft 5 OftW dupeacn Form subwdao•Sewage Dispo9al sys+om•Page 3 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse Owner Owner's Name information is Centerville Ma 02632 4/1/2013 ill _. requlred for every State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) 2. System will fall 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 x _ --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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 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 day flow I&ns•I1110 Tdb S ofri=ei Inspection Form.SubsWm SewW D-aposel System•Pago 40117 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse_ Owner Ownees Name information is Centerville Ma 02632 4/1/2013 required for every -- -- state Zip Cade Date of Inspection pegs. CfrylTfswn 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: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal collform 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- 10,000gpd. ❑ ® The system falls. 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 ❑ Cl 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 it 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. t5ms•11110 Us 5 Official UmpeeWn Form-Subswfaee Sewage D:sposat System-Pape 5 of 17 Commonwealth of Massachusetts -UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse Owner Owner's Name Information is Centerville Ma 02632 4/1/2013 _.. required for every cKyrrown 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? ® ❑ 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 WA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 — Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd t5w•1111t) TWO 5 t)MOW Im"etion Forth:Sutivwiaw sewsp ovoso system-Paoe 6 or 17 i e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Address Carole Morse Owner owners Name reformation is Centerville Ma 02632 4/1/2013 required for every page. ctty!Town State Zip Code Date of inspection D. System Information Description: 2 Number of current residents: 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)): 126gpd Detail: 56,000 gallons used 2011 and 36,000 gallons used 2012 Sump pump? ❑ Yes ® No Last date of occupancy: Date Current 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: isms•t 1np Title 5 Ot UX htabeation form:Subuuteoa Sewage Oispoaal System•Pape 7 OI 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse Owner Ownees Name information is Centerville Ma 02632 4/1/2013 required for every - — _ page. Cdyrrovm State Zip Code bate of inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General information Pumping Records: Source of information: Last pumped approx.2 years ago,Source was Current Owner Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1000 gallons How was quantity pumped determined? Gauge on pumping truck Reason for pumping: Inspection and Maintenance 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/Altemative 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): Cesspool is being used as a modified septic tank with 2 leaching pits IStM•11I10 Troe 6 Oftal Umpadim Form$Wswfaw Sawap Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road , Property Address Carole Morse owner Owners Name information is Cent Ma 02632 4/1/2013 Centerville _._ required for every — - State Zip Code Dale of Inspection page_ cityrrown D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 46 years old with a added precast leaching pit in 1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2.5 Depth below grade: feet Material of construction: ®cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): No evidence of leakage from visible sections of pipe Septic Tank(locate on site plan): 1.0 Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ®other(explain) Approx. 1000 gallon Concrete Block modified cesspool If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 6'x5' Dimensions: —_ 101, Sludge depth: -- '- *no-11110 Tide 5 Oftia1 Inspection Form Subsurtaee Sewage Dsposat System"Page 0 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse Owner Owners Name information is Centerville Ma 02632 4/1/2013 required for every Cienter n state Zip Code Date of Inspection page. D. System Information (cost.) Septic Tank(cant.) Distance from top of sludge to bottom of outlet tee or baffle 36" Y Scum thickness 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 19" Tape measure and mesuring stick 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.): Inlet and Outlet tee's in good condition, Liquid level at outlet invert. No inflow of water observed after pumping 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: it; 15ins•11$10 T"5 Off"lnsDeWon Fam:Subwrface SOwsa9 Dismso synem-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 168 Stoney Cliff Road _ Property Address Carole Morse Owner Owner's Name information is Centerville Ma 02632 4M2013 required for every State Zip Code Date of inspection page. Cityrrown 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: Material 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 t5ins•11110 TWO 5 Official Impaction Fam:Subsurface Sewage Disposal System•Pap 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse Owner Owner's Name information is Centerville Ma 02632 411/2013 required for every State Zip Code Date of Inspection page. cityrrown D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Nona 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. El Yes ❑ No 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: t5ft•t ltio Trge 5 OK001 h 3MCt9M Fam S bsu ace Semgp 04posat System.Pape 12 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff_Raad -.--- Property Address Carole Morse_ --- Owner Owner's Name information is Centerville Ma 02632 _ 4/1/2013 required for every -- ` page cityfTovyrl Stale Zip Code Date of Inspection D. system information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): no evidence of hydralic failure or damp soil,vegetation fair, Liquid level in pit 1 was at 54", Liquid level in pit 2 was at 1"with staining at same, no solids carryover _._._ Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 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 15uts•11110 Tale 5 Official Inspeaon form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 168 Stoney Cliff Road Property Address Carole Morse Owner owners Name information Centerville Ma 02632 411/2013 required for every Page. City/Townstate Zip Code bate of Inspection 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.): tNns•t v10 TWO 5 Offidel Impealon Form Subsurfam Sewege Dispoael System•Pepe 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse _ Owner owner's Name information is Centerville Ma 02632 4/112013 raqulred for every page. City/Town State Zip Code Date of inspection 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 public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately P:z a sl.o P;i t +�c,od:f lea CA.SSpoo 1 'ka 3h.o 3S q S3.o FaoesY o 4 Hods. Zr►c�c+e.,.r,csm� i5 ns.1 i�ip Ift 5 of6oal U%speaion Ferro:&Amafsw Sewage Devosat System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road - Property Address Carole Morse Owner owner's Name infomlationis Centerville Ma 02632 4/1/2013 required for every - page crtyrrown 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. none encountered 12' _ 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 ate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Cl 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: Use of Construction permit dated 1/1311989 on file with the BON Before filing this Inspection Report,please see Report Completeness Checklist on next page. GAS•11110 TWO 5 Ouaer Nspection Form:subs 06M Strwago Disposw System•Page 16 or 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 158 Stoney Cliff Road Property Address Carole Morse Owner Owner's Name information is Centerville Ma 02632 4/1/2013 ery required for every state Zip Code Date of Inspection page. cityrrown E. Report Completeness Checklist ® Inspection Summary: A, B,C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® 'Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I i tSua•11fto Title 5 Otr=W trtapetdon Form:Subaur(GW Sewage Oilposet System•Page 17 of 17 Monday,April 1, 2013 9:31 PM Subject:158 Stoney Cliff Road Centerville Date: Monday,April 1,2013 8:50 PM From:Stephen Cook<inspect04@gmail.com> To: Bernie Lynch<b.lynch@inspecthouse.com> Hi Bernie Thanks again for coming down the Cape to do my fiance's Title 5 inspection If all looks fine could you send the original to me Stephen Cook PO Box 298 Sagamore, MA 02561 Thanks again Now I owe you a glass of milk I Page 1 of 1 TOWN OF BARNSTABLE I-OCeTION_� _ S olafy VILLAGE �` C ut�t__ ASSESSOR'S MAP & LOT qn INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY �Q— LEACHING FACILITY Atype) _ Pm s NO. OF BEDROOMS_ PRIVATE WELL. U BLIC '�'A1TER _ BUILDER OR OWNER\C� DATE PERMIT ISSUED- --DATE COMPLIANCE ISSUED: VARIANCE GRANTED: �f�L1 -s t% 6 `1 i THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ....---tea. ..................OF.. �"$- 5\V� ie�S ApplirFation for Disposal Marks C onstrurtion remit Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal System at: S. Location-Address or Lot No.• Owner Address a `�� `�... 1a�Ca r- ---�-6-•----...(:--£:y4'1_jW�V-� A Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No, of persons............................ Showers — Cafeteria a' Other fixtures -•-•-•---------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. t� Septic Tank—Liquid capacity............gallons 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 tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.____-_-_______--.._--. 94 ....•---••-------------------•••--......••-••-.......... .......................&...... -•--------�� •��` U Nature of Repairs r Alterations—Answer when applicable_-------- . �•........... MP......-�44 .IDS_ ---------•--• -•-.-.-------•--------•-•----••-•----••-•---•--------•...............•-•--•--.....---•_------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with TT/•1F^ the provisions of :T t IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be ng� sued by the f health. Signed --..�. - -- ........ ate �Application Approved By--•••..............• -�� f------/.•3 m_ff ¢ Date Application Disapproved for the following reasons--------------------------------•-----------------------•--------------------------------------------------••--•- QQ nn Date PermitNo........91."...%17......................... Issued_--•---------------------------------•-----•---------- Date 5 4 No...... .....: :. Fps... . .. --... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH AllpfirFatiun for DiupuuFal Works Tonstrnrtion Frrmit � Application is hereby made for a Permit to Construct ( ) or Repair (t.4'� Individual Sewage Disposal System at: .._...a.__...-• ------ ----------------------------•-----•----•-•--------_......----..._-•------------------------------- 2 Lo tion-Address S(' CC or Lot No. ......................— ----•.......................... Owner ® Address W \C '4...... n i U.. ._ 6 0 3 Vl `t f--�1 kJ6,h "PAA. a ... \--- t.... --••---------------------------•-------• .... - Installer Address d Type of Building Size Lot............................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............................................gallons per person per day. Total daily flow......................................._....gallons. Gd Septic Tank—Liquid'capacity__._.__.____gallons 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 tank ( ) Percolation Test Results Performed by--------------------------------......................................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------- Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 94 ---•----•---....-•---••----••------•-------•---•---•--------------------------------•--•••-........................................--•---- Description of Soil.......... ------------0 -. .......... u ' --•--------------------Z�-----=- '--` ° rc,g,v y....._.. x W --------------------------------•-------------- •--•-----•----------••-•----•--••--••-•-•--•---•-•-•----•-•--•-----••-.-._...----•-•--•-----•---•--•-•--•---••------•--••=------•--•-- x :is----------- U Nature of Repairs or Alterations—Answer when applicable........!vas vk..:............?4_!tp!;a_____�'� ................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'ILE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bqca,15sued by the 4ax._d.-.,-�of}he_ alth 1 Signed - --`'=C ................... ............��•� -�- Dafe Application Approved By..................... ........................... ...........z- !-_3-- tP, 4/ Date Application Disapproved for the following reasons:------••••---•---•--•----•-••--•-•-------•-•-••---•-•-••---•----•-•----••-•-•---•-------•-----••-----.......•--- .................•--.........----•----------•------------._...---------------•--.......-•------......-•--•-------------•-------•--•--•-•-•-•-•-••••••-•-•---••--------•--------•-.----------•••...------ Date V17 = Permit No........ -�---------1--.F......................... Issued-----•------------------------------------•------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................OF.:..`fig �C yNS\ ` '�:K , .................................... TUr#ifirFatr of Touapfianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired b -------------1C� U 1\`-�=:\C�t ----•--•---------•------------•--------------------•-•------------------------•--_____--•---•------------•---•--•------------- I taller at---------+=� --- ----s;i�y.a y-._....C-�'=1--.- `----------�-t�_. ..........0..-c-"�\.--V..j-4--'-..=`'..." .'-----------------------------•-- has been installed in accordance with the provisions of TI T IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit 'o.............. '1_- _�___._____ dated................................................ 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 "` ::...................OF....�� .cZ:.`.NS- \.: S ._.._....._...._...._.._...... y�9 No._._!�/.'` �_ FEE..';�n.... "- DiulrooFal Turku �unrton pr�tti# Permission is hereby granted �C,S �'' __-___--l_-`---.�C_ ..-`_... to Construct ( ) or Repair ( L,<an Individual Sewage Disposal System at No.. 1 - L C `-� _ C?'. r1'�?'Q \l t� �... 5'a -------------------------------------•----••-•---••........=-•------ ..................... Street -7 as shown on the application for Disposal Works Construction Permit No.tr _2 6___ Dated.......................................... ---------•-------•------•-•--•----__---- > ----------------------•------ oard of Health DATE.................. ••_-----•-- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS TOWN OF BARNSTA.BLE LOCATION^Sk SF.WArE # VILLAGE CS4Uxwt" ASSESSOR'S MAP &t LOT INSTALLER',S NAME & PHONI? NO. Oiek�.4 CowgT _ SEPTIC TANK CAPACITY LEACH114G FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL U FSLIC WATER BUILDER OR OWNER \C DATE PERMIT ISSUED:_/ DATE COlIPLIANCE ISSUED: VARIANCE GRANTED: Yes � _ No ✓'" �__,�� 19 4 r i . . . 1 . . . . :.. ., . . . . . ... . .. .. : . _ . . ... .. . ... . ... . l.�./: : L.._..._ .. . . ... ...... . . .,. . .. . . .. .. . ... . . .... .... .. .: . . . . .. .: .... . .. ..... . t I . . : . I . ...-...:.....— .........;—......;............—i....�...11.1;....—..—......I............I................. . 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