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Home My WebLink About0170 TARAMAC ROAD - Health 170 Taramac Road Centerville P y A = 169 105 Aff JaaFo�ti //// UPC 17534 NI.21, 53COR 'bsrc ' KASTINGS.UN Commonwealth of Massachusetts 108 :�---_ �;� Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TA_RAMA_C RD Property Address-----------^--------- -----.--- -- ' JENNIFER DRISCOLL I Owner Owner's Name — information is' CENTERVILLE required for every ___._ _.____ MA_ 02632 5/27/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. filling n A. Inspector Information SJd� 15y3� fillip out forms on the computer, use only the tab -Trevor Kellett key to move your Name of Inspector -- —.._-- --- ---— cursor-do not Ca e Cod Se -tic Services use the return —p — p -------____-_ _— __ key. Company Name --- -- — r.' 350 Main St. ran Company Address --- — W Yarmouth MA 02673 ` City/Town State Zip Code 508-775-2825 _31-13744_ Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails _5/28_/2021 Inspector's Signature -- - - Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under erthe 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 i Commonwealth of Massachusetts ,E� Title 5 Official Inspection Form yr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMA_C RD .�' Property Address -------------------------- ----- — — — JEN_NIFER DRISCOLL Owner Owner's Name ---- -- —---- information is y CENTERVILLE required for ever MA 02632 5/27/2021 _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM IS IN WORKING CONDITION 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): 15insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC_RD Property Address ---- ------.-- ------------- -- JENNIFER DRISCOLL Owner Owner's Name --- --- --------- --- -- informat required is CENTERVILLE required for every _MA 02_632 _ 5/27/2021 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.7/2 612 0 1 8 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC RD Property Address — JENNIFER DRISCOLL Owner Owner's Name ---- -------------- ----- — information is CENTERVILLE required for every __ _ MA__ _02632 5/27/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: * This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of (Massachusetts `title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC RD Property Address -- JENNIF_ER DRISCOLL _ Owner Owner's Name ----^— information is CENTERVILLE required for every MA_ 02632 5/27/2021 page. City/Town 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 '/2 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 avid nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC RD Property Address --- -- JENNIFER DRISCOLL Owner Owner's Name — information is CENTERVILLE _ _ required for every MA _02632 5/27/2021 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 C.4 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)] 5insp doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 yA', Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t AF Q _- 170 TARAMAC RD Property Address------------------------------ -------------- — — -- JENNIFER DRISCOLL Owner Owner's Name— - — — — — information is CENTERVILLE _ required for every _ MA 02632 5/27/2021 _ page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3--- Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 Description: Number of current residents: VACANT 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: VACANT- 1 YEAR t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rr T r' 170 TARAMAC RD Property Address JE_NNIFE_R DRISCOLL Owner Owner's Name ------- -- information is EVI TERLL CEN required for every - - ER -LL -- ------ - - _MA.-- 02632 _ 5/27/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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: 9/2019 PER HOMEOWNER Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: ---- ---- ----- --- —_ gallons How was quantity pumped determined? ------ — — Reason for pumping: - -- ---- -- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ 1_70 T_A_RAMAC RD Property Address------^- -------- ------- — JENNIFER DRISCOLL Owner Owner's Name information is CENTERVILLE MA 02632 5/27/2021 required for every ---- - ----- ...- - -- ------------- ----- - 2632 — - —-- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1978 PER ASBUILT ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer (locate on site plan): Depth below grade: 29" ___________ feet -- Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): --- Distance from private water supply well or suction line: -10,+ ---- feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED —` — t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts {y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC RD Property Address— -- ---,---- —.-- --- -.-- — JENNIFER DRISCOLL Owner Owner's Name -- information is required for every CENTERVILLE MA 02632 5/27/2021 -------__—--- ---------- -- ------ ---------------- -- ------� _—. page. C—ity/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 19 -- feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years" -- — Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON - 1 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? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. INLET COVER AT GRADE t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsirface Sewage Disposal System•Page 10 of 18 < ' Commonwealth of Massachusetts Ri = f� Title 5 Official Inspection Form - - _) Subsurface Sewage Disposal Systern Form - Not for Voluntary Assessments =A� =, y 170 TARAM_AC RD _. Property Address -------- ------...----------- -- JENNIFER DRISCOLL Owner Owner's Name information is CENTERVILLE required for ever MA 02632 _ 5/27/2021 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 El other (explain): Dimensions: ----- ..._._........ -- -- --------- Capacity: gallons Design Flow: gallons per day — l5insp.doc•rev 7/2(3/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC R D Property Address - JENNIFER DRISCOLL Owner Owner's Name -- — — ----- ------ -------- — information is CENTERVILLE _ MA_ 02632 _ 5/27/2021__ required for every __ ___—_—__--_-- _ page. City/Town 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 EVEN _ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp doc•rev.7/26/2018 Title 5 Official Inspection Form:SUbSLlrface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Foy r) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAM_AC RD _ Property Address -- JENNIFER DRISCOLL Owner -----------------...------....----......—_—..._—._-____..----_---------------------- Owner's Nameinformat — -- ion is CENTERVILLE requiredequired for every _..._ . _ MA 02632 5/27/2021 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: 1-6'X6' - — ❑ leaching chambers number: - ❑ leaching galleries number: -- ❑ leaching trenches number, length: ------------ ❑ leaching fields number, dimensions: — - ❑ overflow cesspool number: - ❑ innovative/alternative system Type/name of technology: — -- ------ -- — t5insp.doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form •1<I— {- '� f'I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A 1=0 r 170 TARAMA_C RD_ Property Address - ----------------------- -- JENNIFER DRISCOLL Owner Owner's Name --�-- ------information is CENTERVILLE MA 02632 5/27/2021 _ required for every page. City/Town - ---- -- ---------- — _ State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6'X6' PIT WITH 1.5' OF STONE FOUND DRY DURING INSPECTION WITH STAINING TWO FEET DOWN FROM INLET. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert —. Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5nsp dcc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 18 r - ti Commonwealth of Massachusetts ^ Y,s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC RD . Property Address �----- ---- ------ --- ------- ----- JENNIFER DRISCOLL Owner Owner's Name information is CENTERVILLE MA 02632 5/27/2021 required for every -- ------------_...------- ---_--- .._... ----...-- ---------- - ---- — -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: -- ---- ----- ----- -_ Dimensions --- ------- ---- Depth of solids —----------..-- ------ -----._._. Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) t5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC RD Property Address JENNIFER_DRISCOLL Owner Owner's Name — ----- information is CENTERVILL_E _ _ _ MA _ 0_26_32 _ 5/27/2_021 required for every _�. _ __ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i q0 t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i Commonwealth of Massachusetts }= Title 5 Official Inspection ®r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC RD Property Address ------ -- — JENNIFER DRISCOLL Owner Owner's Name ---- ---- -------�----requiinform re Lion is CENTERVILLE required for every IVIA 02632 _ 5/27/2021 _ 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: +15' _ _`— 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: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: HAND AUGER PERFORMED ONSITE AT TIME OF INSPECTION TO 152' ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT 8' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp doc•rev 7/2312018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts z Title 5 Official Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 TARAMAC RD Property Address '- JENNIFER DRISCOLL Owner Owner's Name ------ - - -- ----------- ---— —reinformat quired is CENTERVILLE MA 02632 5/27/2021 _ required for every __.._..--------- ---- -- ----------- ---- - ----- ------- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® 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 / li l5insp.doc•rev.712612018 Title 5 Official Inspection Fcrav Subsurface Sewage Disposal System-Page 18 of 18 L0MMONWI:A1.,TFI OF MASSACI-IUSETTS EXI�CUTIVI�: UhFI('L; (.)h ENVILZUNMEN'C/1LA1'FAIftb — d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED i V MAY 2 5 0004 TOWN OF BARNSTABLE HEALTH DEPT. Map: Lot: _ Par: TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_170 Tarmac Rd. _ MAR I _Centerville, Barnstable Owner's Name: Susan Allison_ �ARC�� S Owner's Address: _27 Rosewood Rd. LOT _Stoughton,MA 02072 "�-_..—.....�,�_ Date of Inspection:_5/11/04 Name of Inspector: Dion C. Dugan Company Name:_ 1543 Main St. Mailing Address: Brewster, MA.02631 Telephone Number: _508-896-9390 a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ! The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector.and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes wid Comments: *Recommend: Maintenance pumping 3—5 yrs. ****'Phis 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. Page 2 ol" I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_170 Tarmac Rd. _Centerville, Barnstable_ Owner's Name:' Susan Allison_ Date of Inspection:_5/11/04_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of' I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 170 Tarmac Rd. _Centerville, Barnstable_ Owner's Name: _Susan Allison Date of Inspection:_5/11/04_ C. Further.Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system js failing to protect public health,safety or the environment. , 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I 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 welly'. Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 170 Tarmac Rd. _Centerville, Barnstable_ Owner's Name:_Susan Allison_ Date of Inspection:_5/11/04_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _NO_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no - -N/A— the system is within 400 feet of a surface drinking water supply —N/A_ the system is within 200 feet of a tributary to a surface drinking water supply _N/A the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of iuiy 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. Page 5 of I t OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _170 Tarmac Rd. _Centerville, Barnstable Owner's Name:_Susan Allison_ Date of Inspection:_5/11/04_ Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant, or Board of Health _X_ Were any of the system components pumped out in the previous two weeks ? _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection ? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ Was the facility or dwelling inspected for signs of sewage back up ? _X_ _ Was the site inspected for signs of break out'? _X_ _ Were all system components,excluding the SAS, located on site _X_ _ 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 " _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(3)(b)j Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 170 Tarmac Rd. Centerville, Barnstable Owner's Name:_Susan Allison_ Date of Inspection:_5/11/04— FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): _3_ Number of bedrooms(actual):—3— DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330_ Number of current residents: Does residence have a garbage grinder(yes or no):_no_ Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no):_no Seasonal use: (yes or no):_no_ Water meter readings, if available(last 2 years usage(gpd)): 2002:_30,000, 2003:`31,200 Sump pump(yes or no):—no— Last date of occupancy:_OCCUPIED COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_unknown;owner Was system pumped as part of the inspection(yes or no): NO_ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy NO_Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank ___Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed_12/20/1978 (26 yrs. ol(l)—B.O.H. Records Were sewage odors detected when arriving at the site(yes or no): NO-- Page 7 of' I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_170 Tarmac Rd. _Centerville, Barnstable_ Owner's Ngme: _Susan Allison_ Date of Inspection:_5/11/04 BUILDING SEWER(locate on site plan) Depth below grade:_2.5'_ Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_N/A Comments(on condition of joints,venting,evidence of leakage,etc.): _Joints are tight,venting is through the roof, no signs of leakage. SEPTIC TANK:—YES—locate on site plan) Depth below grade:_17"_ Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_1000 Gallon_ Sludge depth:_6"_ Distance from top of sludge to bottom of outlet tee or baffle: 24"_ Scum thickness:_1" Distance from top of scum to top of outlet tee or baffle:_6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined:_by tape and rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): _Recommend cover be built up on septic tank w/in 6" of grade and Septic tank be pumped next year.Tank and tees in good condition,no sign of leakage. *Recommend: Maintenance pumping every 3—5 yrs. GREASE TRAP:_N/A_locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or-baffle- Date of last pumping: T Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels i as related to outlet invert,evidence of leakage,etc.): Page 8 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _170 Tarmac Rd. _Centerville, Barnstable_ Owner's Name:_Susan Allison_ Date of Inspection:_5/11/04_ TIGHT or HOLDING TANK:_N/A_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_YES_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0"_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box is level with some signs of carry over and no signs of leakage PUMP CHAMBER:_N/A_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_170 Tarmac Rd. _Centerville, Barnstable_ Owner's Name:_Susan Allison_ Date of Inspection:_5/11/04_ SOIL ABSORPTION SYSTEM (SAS):_YES_(locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number:_one 6' x 6'w/ 1'stone_ leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.):_Pit found w/49"of liquid in it. No staining,so sign of failure. CESSPOOLS: N/A_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): *Recommend: Maintenance pumping every 3—5 yrs. PRIVY:_N/A(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.): . Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_170 Tarmac Rd. _Centerville, Barnstable_ Owner's Name: _Susan Allison_ Date of Inspection:_5/11/04_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or. benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. � O C I-} ovSE 176 - I� - .36 'Ll� G f3 - C m 13 _ a : 32 ' I r� Page I I of I I OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SVSTf'M INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _170 Tarmac Rd. " _Centerville, Barnstable_ Owner's Name:_Susan Allison_ Date of Inspection:_5/1 1/04_ SITE EXAM Slope Surface water, Check cellar Shallow wells Estimated depth to ground water_20—feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: You must describe how you established the high ground water elevation: By perk test on Sept.20, 1978, 12' deep no groundwater encountered. And by U.S.G.S.Atlas H A-692. -07 r7 d 7 .�� LOCATION SEWA E PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS B U It D E R OR OWNER J . SP i DATE PERMIT ISSUED �o -,20_, DATE COMPLIANCE ISSUED �� , 3�r � �� 3�s ry� ��i tY!'� X1 µ 1 'No.....f1.. c,1r...� y A, Fns........... .y THE COMMONWEALTH OF MASSACHUSETTS J(�( BOAR® OF HEALTH �10 - - 'C?Gc.).N .............OF......�19 /4�.. -t/9.8. ...................................... Appliratiou for Uhipoiia1 Works Towitrurtiou Vamit ' I Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: .T-- RA&A—c....R.A .:.....CEI r�'2V� .4------------- SOT_.....-- -...Y. ------......-----------------...---------.............. Location-Address or Lot No. �'� � ._._�C,,....5± ►-r ------------•------------------------------- ------�w��. %LF ........................................................ Owner Address wvETo2,a.t�10..... ,os: ----------------------•. ------..... usT0..!i ....................................................--- Installer Address dType of Building Size Lot.�.'_.3 ......Sq. feet U Dwelling—No. of Bedrooms.....•.•._...---••-......--•••----•----Expansion Attic (1vt)) Garbage Grinder (No) Other—Type of Building ....N A-__--.._--_. No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ----------------------------•--. - W Design Flow.........../ll?...................•..gallons per per day. Total daily flow_____..._ _.. Q.._......._._____._..gallons. WSeptic Tank—Liquid'capacity/Q.4?t-gallons Lengthxg_'K" Width._ ."61.". Diameter________________ Depth__S-',R-`l. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. � � Seepage Pit No.....___�........ Diameter----- _..______. Depth below >nlet___.�__r........ Total leaching area. . .00...s. q. ft. Z Other Distribution box (� Dosing tank ( ) ''' Percolation Test Results Performed by.. o 1Qc�---_A.....6_er /LL?__�.S Date----�Ct�T._��__1�� Test Pit No. 1..4.�__;Z_..minutes per inch Depth of Test Pit.... `..._... Depth to ground water.._dlo�l�'...-_. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-•••---•--------•--------••--••••••-•--•--••-•-••----••----••••-•-•-••.......--•-•-•---------------........................................................ O Description of Soil_ _-0--- -a-•Y ......AA1,0..........57V_.®��ta1 -------------------•-- . . --------------•--------------- x ...�-. '-30'•=------1V'�/1_.uV.....4--I.Y.2).....AIV..D-----�ot-.�......�/�911��.... V `. tr 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 iITL LE 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.., �....��"'+ ........................ ................................ Date Application Approved BY .............1l Date Application Disapproved for the following reasons----------------•-•---------------------------------------------•---------------------------•----•-----•-•....... -----------------•-••-----....------------------•-••----------------•-----•------------.......--------------•••-•••----•-•-•-•._..._._..••-••---------------••••-----------------...•••-•••••••••-----•- Date Permit No......... . ....................................... Issued....................................................... Date ,s Fps.. ..��"�d!} No.....,:. ... .. ......,,,,,•. THE COMMONWEALTH OF MASSACHUSETTS Jt+y( BOARD OF HEALTH R� ..............OF..... ....................................... App irtttion for Di ipus al Works Tonstrurtion "permit Appl'�ation is hereby made for a Permit to Construct (�'' ) or Repair ( ) an Individual Se � bisposal System at: r IV ._.... .. .. .. —� Location-Address - or Lot No. ........ft :1x. _.._.i ....__5`fir E. ...:......................................... ... ............... Owner _ Address -• -•--•........ ............ .........----•.....................---.................. Installer Address dType of Building Size Lotg/&_119.......Sq. feet Dwelling—No. of Bedrooms......... ..............................Expansion Attic ,(N.0) Garbage Grinder (JO) per., Other—Type of Building -__&/f�............. No. of persons_________._..___....___.____ Showers ( ) — Cafeteria ( ) a' Other fixtures _________________________________ v2aar+ W Design Flow............//.Q................•..___gallons per person per day. Total daily flow-------- _30.....................gallons. WSeptic Tank—Liquid capacity hR.0..gallons Lengtht6.!r.". Width:'��''r/.o.". Diameter................ Depth_6_W..,. x Disposal Trench—No..................... Width.................... Total Length................. Total leaching area....................sq. ft. Seepage Pit No........._./--------- Diameter....&........... Depth below inlet.... Total leaching areag.? 4>...sq. ft. Z Other Distribution box el' Dosing tank ( ) ;- `" Percolation Test Results, Performed b Q/ :ly`,..___ _...._._�._f! %jI. GG�_ `_ Date..._ ,tea Test Pit No. 1.-4-'�-•.•�-,.....minutesperinch Depth of Test Pit.... Depth to ground water.. 1�?!�!_�____. i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •--•---------------------------•--••----------•-......_..............................-------•--••---......................................................... O Description of Soil.... !1-----•.4.?''.n..--......5� tr r .------------------------------------•----•-------•---------•--- x ...%� %..' . ' °�'_ �5_,,...... ? P S�+t�e' !9-t4!t ✓_c tr T-----.'1_A.e4: V y i� 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 iITL: p 5 of the State6anitary Code— Theundersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Ile Signed••-•• -�°"°� VL• �_ • J ' D to Application Approved BY _::. .... �'` ��= ...... Date Application Disapproved for the following reasons-...................==------------•--•--•--•---•-........................................................ ......--•-------------------------•-•--------.......------....•...--••---••---••-•-----••---------•_. :.. ; v . a 1. Date,' ti . o� Permit No..... fl .5-----------------•---------•--..•.. IssuedL........... -•--- .... Date d4.�,i6., THE=`COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !u�:t. ....."......OF... 1 1 ` ... ��.....�........................................ C�rr#�firtt#�.�'af nm�littnrr /'` THIS IS TO CERTIFZ, That the Individual Sewage Disposal;System constructed O or Repaired ( ) by C.T t<'1 .1c1-_....L�:t �'- ...... ......... Installer atf '� A =._C.EA,7# •••---••••••-•--•------•--••-•-•--•..............•--••----•-•- has been installed in accordance with the provisions of ?'I;mLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... .................................... dated_........_.................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE �r�w3.� w mxx»•+r. 1,-• 'r+.: :n .. _� InspectorC5'4�......s, 3` �75_ -� -m. h iF�� .S'ta •rx X. ��'' `sue e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - �! �l !ti�...............OF.... ! 1 -.t4).. .7i.�:�1AJ.................................. .............. ` No.- ... �....... FEE........................ ,,.�.r.�""' i.- Permission rs ereby grave ......._.._.! , to Construct (�j) or Reparr�( ) :n Indivrr1ual Sekrage Disposal System atNo.......-C-T.______M------- ------1� `*� ........ -•--------------------•--------------------------•---- Street as shown on the application for Disposal Works Construction P4mit ----------- Dated.......................................... •___• _ __ .. � _ _• .... ................................................... j �� ear Board f I{ealth t.•• DATE.....< ........................................ I FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ._ �. �T 151. "f SEPT. as , /9 78. MST, RESERVE k PA�� . !`�!CI R f�AY,• �!d 5/'EC TO R La r 14 x .. a, f r b 5c� �.,,5," `,k . ELEV, /7, p, ai8`38 _ - LEA� H j0 SEPTIC Pl T TANK .0=�4 L0*19M AND ` 4b. r. SLJQSOIL ,5: a9 --36 MED SAAW . AND LT, GRAVEL y l4 36 '- /44 /S9ED/UN! 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