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HomeMy WebLinkAbout0085 THISTLE DRIVE - Health 85 THISTLE DR, CENTERVILLE A= 148-019 No. 42101/3 ORA ESSELTE 10% O O O O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 85 Thistle Drive Property Address Steven Babbitt Owner owner's Name information is required for every Centerville MA 02632 6-4-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �ollIIIUUpr//�'��i, on the computer, ��ZH OF M use only the tab key to move your 1. Inspector: cursor-do not James D.Sears use the return JA Name of Inspector ' key. Ca ewideEnter rises LLC p p N Company Name �';'c T ;�6 153 Commercial St. �i,,F�rsf IN � Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-513 spectors 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. ""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. ��►z/i3 t5ins-3/13 Title 5 Offi' on Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner owner's Name information is required for every Centerville MA 02632 6-4-13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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.Any failure 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 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): II t5ins•3/13 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 is less than 6"below invert or available volume is less than%day flow iX-35 t5ins•3113 Us 5 offidal on Forth:Subsurface inspedi Sewage Disposal System•Pape 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. Cityrrown State Zip Code Date of Inspection 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. ❑ [D Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3M 3 Title 5 Officief Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. Cityrrown 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? ❑ 0 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)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal Tank D Box and two pits. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2011-25,000 Gal g ( Y g (gpd))' 2012-25,000GaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: present Date CommerciaUlndustrial 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-sanitarywaste discharged as e d scha ed to the Title 5 system? Yes No 9 ❑ ❑ Water meter readings,if available: t5ins-3113 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ewide Source of information: 08/13 Cap �i Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previous inspection re cords, 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): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner owner's Name information is required for every Centerville MA 02632 6-4-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Tank and pit around 19721 Newer pit 1995 permit # 95-933. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"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.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 17"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) II If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000Gal.Precast Sludge depth: 1" t5ins-3113 Us 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape-Past-Report Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level w/in and outlet tee's center cover for pumping. No sign of leakage or over loading. 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 t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °t 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is Centerville MA 02632 6-4-13 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Flame information is required for every Centerville MA 02632 6-4-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is 16"x16"-25" below grade w/two line's out. Box is clean and solid. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r( 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. City[Town state 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: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precast pits. Pit# 1) Older pit w/cover at 6"pit was failed around 1990. Pit#2) Newer pit installed 1995. Pit and cover at 27"below grade. 6"water in pit w/stain line at 18". No sign of over loading or solid carry over. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (corn.) 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 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 G� 0�t 10 4 `3 , 101r 31F 0 � t5ins•3r13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells AJO 30+' Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.W. of past report. Bottom of pit at 9'. Bottom of pit at 21+'above G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Mist Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Y Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Thistle Drive Property Address Steven Babbitt Owner Owner's Name information is required for every Centerville MA 02632 6-4-13 page. Citylrown State Zip Code Date of Inspection 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I f Commonwealth of Massachusetts i Title 5 Official Inspection Form ' i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is , required for CA -V j 1'11 1,,-,/ every page. Cityl I own �` ee State Z Code I i P Date of Inspection ! Inspection results must way. be submitted on this form.Inspection forms may not be altered 'n ny . Important: When filling out A. General Information forms on the �/ f computer,use Inspector 1 1 !!!I only the tab key P i move your ,,���� ` 3 cursor-do not v� c use the return Name of Inspector key. J,� Company Name � Company Address A/V ANill/ ! 1. City/Town % J r State Zip Code Telephone Number License Number I { B. Certification I certify that I have personally inspected the sewage disposal system at this address and that t ie 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 o i on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15 40 'f Title 5(310 CMR 15.000).The system: . Passes ❑ Conditionally Passes ❑ Fails a ❑ Needs Further Evaluation by the Local Approvin uthority / c1 ? or's ature / ! w Date et:r The system inspector shall submit a copy of this inspection report to the Approving Authorit (B and rn of Health or DEP)within 30 days of completing this inspection. If the system is a shared sys em br has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the The original should be sent to the report to the appropriate regional office of the DEP. syste o er and copies sent to the buyer,if applicable,and the approving authority. (n **"This report only describes conditions at the time of inspection and under the con s o!use at that time.This inspection does not address how the system will perform in the futti e u der the same or different conditions of use. i i t5insp.doc.0&06 ! Title 5 Official Inspection Form:Subsurface Sewage Disposal SysteoiI•Page i 1of is V i Commonwealth of Massachusetts ; Title 5 Official Inspection Form Subsurface`Sewage Disposal System Form-Not for Voluntary Assessments ' S'T/1 04, r i d. lG Property Address Owner Owner's Name information is required for 6 C "V 7, 11!/t every page. City/Town State Zip Code Date of Inspection { B. Certification (cont.) { Inspection Summary:Check A,B,C,D or E/always complete all of Section D ' I A) System Passes: 1 have not found any information which indicates that any f the failure criteria describ a� in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: i { I B) System Conditionally Passes: I ❑ One or more system components as described in the"Conditional Pass"section need o be replaced or repaired.The system,upon completion of the replacement or repair,as ap�roved by the Board of Health,will pass. Answer yes,no or not determined((Y, N,ND)in the❑ r the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years • d*or the septic structurally unsound fil p t IK+�►I'tank fa metal or no is tration or tank failure is immi'ent System will pa . spection if the exis' g tank is replaced with a complying septic tan ;as j approved b e Board of Health. *A m I septic tank will pass. spection if it is structurally sound,not leaking and if a C ertificate of mpliance indicating th the tank is less than 20 years old is available. ND plain: Observat' n of sewage backup or break out or high static water level in the distribution 3ox due to brok or obstructed pipe(s)or due to a broken,settled or uneven distribution box. S sterP will ss' spection if(with approval of Board of Health): { ❑ broken pipe(s)are replaced ❑ obstruction is removed Minsp.doc•06/06 Ttlle 5 official inspection Form.Subsurface sewage Disposal Systerli Page 2 of 15 } I I, i i � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Properly Address �^ i Owner fa Gov �r- Owner's Name information is �� f required for C F /y 74F a'C �pd every page. Cltylrown Stage 21 Code d - P Da a B- Certification B) System Conditionally Passes(cunt.): ❑ distribution box is leveled or replaced ND Explain: i 1 i f i ❑ The system required mpi more than 4 times a year due to broken or obstructed p pe(s).The system will pass inspe . if(with approval of the Board of Health): i ❑ broken pipe( a e replaced i ❑ obstructi is rem ved f ND Explain: j i i i i C) Further Evaluation is Require w e Boa of alth: i ❑ Conditions exist which require further eval ti y the Board of Health in order to de t rmige if the system is failing to protect public heal ety or the environment. 1- System will pass unless Board of th determines in accordance with 310 MR j 15.303(1)(b)that the system is not toning in a manner which will protect public health, safety and the environment: i ❑ Cesspool or privy i ithin eet of a surface water ❑ Cesspool or iv y vy is within 0 feet of a bordering vegetated wetland or a salt m rsh 2. System will fail unless t oard of Health(and Public Water Supplier, if any) determines that t syst is nctioning in a manner that protects the public health, safety and environ e ! } ❑ The system has a se p is tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface ater supply or tributary to a surface water supply. i ❑ The system has a s tic tank and SAS and the SAS is within a Zone 1 of a pub is ester supply. ❑ The system has a,-septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insP.doc•08106 Tide 6 OBidat Inspection Form:Subsurrace Sewage Disposal System Pago 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection on Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prop�ertyy Address 1 Owner Owner's Name information is required for Z)e 4/-/- GZ every page. City/Town t State Zfp Code Date of Inspectio s IS. Certification (cont.) C) Further Evaluation is Required by the Board of Health(cant.): ❑ 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 dete ine distance: i This system passes if the well ater ana erformed at a DEP certified laboratory,f r col iform bacteria indicates absent an a presence of am is nitrogen and nitrate nitrogen is eq jai to or less than 5 ppm,provide at no other failure criteria triggered.A copy of the analysis must be attached to this form. 3. Other i i i i D) System Failure Criteria Applicable to All Systems: i i You must indicate"Yes"or"No"to each of the following for all inspections: i Yes No ❑ Backup of sewage into facility or system component due to overloadei J or I clogged SAS or cesspool ❑ 01-� Discharge or ponding of effluent to the surface of the ground or surfac waters due to an overloaded or clogged SAS or cesspool i ❑ 2 Static liquid level in the distribution box above outlet invert due to an o erloaded or clogged SAS or cesspool ❑ Efll�- Liquid depth in cesspool is less than 6°below invert or available volu a is l than Y day flow ess ❑ Required pumping more than 4 times in the last year NOT due to clo obstructed pipe(s). Number of times pumped: 9 led or ❑ y portion of the SAS,cesspool or privy is below high ground water a evation. Any portion of cesspool or privy is within 100 feet of a surface water supply' tslnspdoc•08ro8 r tributary to a surface water supply. Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 DI 15 ti I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface See Disposal System Form-Not for Voluntary Assessments / I Prope Address Owner Owner's Name information is required for every page. Cityrrown State Zip Code Date f Inspection I B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or n p i ❑ well p privy is within 50 feet of a private water supply ❑ Any portion of a cesspool or privy is less than 100 feet but greater tf an 50 feet from a private water supply well with no acceptable water quality ani ilysW. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less tha 15 qpm, provided that no other failure criteria are triggered.A copy of th a analysis and chain of custody must be attached to this form.] ❑ he system is a cesspool serving a facility with a design flow of 200 10,000gpd. gpd'•: The system fails. I have determined that one or more of the above ilure criteria exist as described in 310 CMR 15.303,therefore the system I ails. The system owner should contact the Board of Health to determine what ill be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility w th a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"o no"to each of the following, in additiot i to the questions in Section D. Yes No ❑ ❑ the system is withi 400 feet of a surface drinking water supply I ❑ ❑ the system is in 200 feet of a tributary to a surface drinking water up ply ❑ ❑ e system' located in a nitrogen sensitive area(Interim Wellhead P otedtion Ar —I A)or a mapped Zone II of a public water supply well If you have answered"yes" ny question in Section E the system is considered a signifi nt tljreat, or answered"yes"in Section bove the large system has failed.The owner or operator ol any;large system considered a signifi nt eat under Section E or failed under Section D shall upgrz de the system in eg onal office accordance of Depth 1 t M 1�304.The system owner should contact the approp ate t5insp.doe-06/06 j Tille 5 olrraial lnspec0on Form:Subsurface Sewage Disposal System Page 5 of 75 I F L i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface age Disposal System Form-Not for Voluntary Assessments Property Address v� A�CiS r �s Owner Owner's Name information is l� required for C 4 fV r h�-2 G✓O every page. cityf'fown K, State Zip Code Dat of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the ollo ing: Yes No �❑ Pumping information was provided by the owner,occupant, El � p nt, or Board f H�alth Were any of the system components pumped out in the previous two ee s? ❑ Has the system received normal flows in the previous two week perio ? ❑ Have large volumes of water been introduced to the system recently r as part of this inspection? ❑ Were as built plans of the system obtained and examined?(if they wE re n(t available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? P ❑ Was the site inspected for signs of break out? ❑ Were all system components,excluding the SAS,located on site? ❑ Were the septic tank P manholes uncovered,opened,and the interior of the t 3nk inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ID ❑ Was the facility owner(and occupants if different from owner)providec with information on the proper maintenance of subsurface sewage disposal syst ms? The size and location of the Soil Absorption System(SAS)on the ite has been determined based on: ❑ Existing information. For example,a p n at the Board of Health. ❑ Determined in the field(if any of the failure crt ena related to Part C is a t iss e approximation of distance is unacceptable)[310 CMR 15.302(5)] t5fnw.doc•o&o6 Title 5 Offidal InSpecgan forth:Subsurface Sewage 01spesal system•Page 8 f 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface age Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name`--� information is required for !V r`,�2 �s✓ _ every page. City/Town 4 State Zip Code Dat of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the ollo ing: Yes No �❑ Pumping information was provided by the owner,Occupant,or ❑ / P Board Df H alth �( Were any of the system components pumped out in the previous two weel:s? 2T" ❑ Has the system received normal flows in the previous two week perio ? El 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 these tic tank ma nholes anholes uncovered,opened,and the interior of the t 3nk 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)providec with information on the proper maintenance of subsurface sewage disposal syst ms? The size and location of the Soil Absorption System(SAS)on the ite h s' been determined based on: ❑ Existing information.For example,a p n at the Board of He alth. ❑ Determined in the field(if any of the failure crt eria related to Part Cis a t issue approximation of distance is unacceptable)[310 CMR 15.302(5)] uwp.doc•88106 Title 5 Offf W Inspecoon Form:Subsurface Sewage 01spesal System•Page 6 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments el Prope Address Owner Own is Name _ information is J� required for *ZipCode�o every page. City/rown State Dat of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): -� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: r Does residence have a garbage grinder? ❑ es No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ es No Laundry system inspected? ❑ Y es No Seasonal use? ❑ Y4S No Water meter readings,if available(last 2 years usage(gpd)): Sump pump? ❑ Y as No Last date of occupancy: D 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. ❑ YE No Industrial waste hol ing tan resent? ❑ Yet No Non-sanitary waste discharged th the 5 system? ❑ Y s No Water meter readings, if availabl . Last date of occupancy/use: Date Other(describe): 151nsp.doc•Gems rrue s Official In spection Form:Subsurface Sewage Disposal Syste •Page 7 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P Pr�Address f Owner r1le- L M't`_' i,S information is Owner's Name required for cizv7P vu every page. Cityfrown State p Code Uate of Inspection D. System Information (Cont.) General Information Pumping Records: Source of information: �J -- Was system pumped as part of the inspection? ❑ Yes E r—N If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank,distribution box,soil absorption rp system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if an ) Innovative/Altemative technology.Attach a copy of the current operation ai ld 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: ' ? 1 4 Were sewage odors detected when arriving at the site? ❑ Yes ; No Mnsp.doc.08M6 TWO 5 OffleW Inspection Forth:Subsurface Sewage oisposal System Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prope Address Owner Owners Name information is required for P i! every page. City/Town State — Zip Code Dat of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: A SO— feet Material of construction: ❑cast iron 40 PVC ❑other : ex lain ( P ) Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete ❑metal ❑fiberglass Elpolyethylene ❑oth r(e plain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Ye ❑ No - - - - - - - - - ------------------- i %x i Dimensions: � S . vOr Sludge depth: Distance from top of sludge to bottom of outlet tee or battle ! 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? WhV.doc-0&06 Title 5 Official Inspection form:Subsurface Sewage otsposat syste •Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary _ Assessments _ ry Property Address F r9' S C '4ts f.E J G"i I Owner Owner's Name information is required for 4C i 'V 1 xe z 441 every page. CitylrownD. State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations,inlet and outlet tee or baffle liquid levels as related to outlet invert,evidence of leakage,etc.): condition,structu al integrity, ANC /� y Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concret ❑metal ❑fiberglass 9 El polyethylene ❑oth r(e plain): Dimensions: i Scum thickness Distance from top of m 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,structur i I int grity, 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 9 ❑polyethylene ❑othe';(ex lain): t5insp.doc•08106 'nue 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prope Address Owner Owner's Name information is required for Cg n.'%f%2 4- every page. City/rown ' � '�v 5 State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cunt.) Dimensions: Capacity: 1 gallons Design Flow: J/ gallons per day Alarm present: ,p`� ❑ 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 con tract(required). Is copy attached? ❑ Yes ❑ No 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 carr.rrovei any evidence of leakage into or out of box,etc.): l VIC- i Pump Chamber(locVonsiten):Pumps in working ord ❑ Yes ❑ No Alarms in working ord ❑ Yes ❑ No I t5lnsp.doc•66/66 1i6e 6 OWMW inspection Form:Subsurface Sewage Disposal System;'Pagel or 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address 017 z OwnerGZ e 4g mot" Owner's Name information is required for Ile— //.Z� 0�6 L every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pu chamb ;condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type. L� leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number. _ ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: i Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp Soil,cor ditio i of vegetation,etc.): r~ t5insp.doc•08106 TIUe 5 Of kW Inspection forth:subsurface Sewage Disposal system•Page 1 of 15 i f Commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form-Not for I_ g p y o Vo unta Assessments ry Property Address ,( Owner Owners Name information is } required for C r N 7 r�- !s / /��,� o-d z 6 / e jr I i every page. Cityrrown State Zip Code Da a of Inspection i t D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration I Depth—top of liquid to i let invert if Depth of solids layer Depth of scum layer i Dimensions of cesspool f I Materials of construction i I Indication of groundwater ow ❑ Yes ❑ N t Comments(note condi' n of soil,signs of by aulic failure,level of ponding,condition of v a I get ition, etc.): i I I i { I Privy(locate on site plan): j i Materials of construction: ; Dimensions Depth of solids I a Comments(no conditio of soil,signs of hydraulic failure,level of ponding,condition of vilgeteetion, etc.): i Misp doc•08MB Title 5 ORidal Inspecllon Form:Subsurface Sewage Disposal System Page 3016 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is required for Al J r J2 a/ �t'L, � every page. citylrown / — n` State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system in udin g ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 10 fee l. Locate where public water supply enters the building. a r = 3 � ' � 7 4 3 = 37 / iL 156up.doc•06/06 Title 5 official frispeUton Form:Subsurface Sewage Disposal Sysle .-Page 4 of 15 , Y t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner information is Owner's Name required for C,(- •-%/.j 6`j every page. CitylTown State Zip Code Da iof pection j D. System Information (cont.) Site Exam: �� •CJ Check Slope fJA 7' 0 Surface water Ae 7' Check cellar DR.. y Shallow wells 6N 2 Estimated depth to ground water. feet Please indicate all methods used to determine the high ground water elevation: i i ❑ Obtained from system design plans on record i 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: i l-)w,�� ❑ Checked with local excavators,installers-(attach documentation) i ❑ Accessed USGS database-explain: i You must describe how you established the high ground water elevation: A/ T A 70 6; 4V p Sv tiL r-h t t- 7 6 !� I 15lnsp.doc-08/00 Title 5 ONidal inspection Farm:Subsurface Sewage Disposal System page 5 of 15 I THE COMMONWEALTH OF MASSACHUSETTS /FEic ae........... BOARD OF HEALTH TOWN OF BARNSTABLE Appliratioit for Di!i.poiul Workii Towitrnrtion run it Application is hereby made for a Permit to Cortstruct ( ) or Repair ( ) an Individual Sewage Disposal System at: - ... .... �. •-• - ----------------•..----•.•.....••...••. Location-i\ ress or Lot No. 1-A "C•e/------- Owner Address a �.tic� f--------------- ---------------- ............ •-----------------------. nstal� Address Type of Building Size Lot............................Sq. feet 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. WSeptic Tank—Liquid capacity............gallons Length................ Width.....----------- Diameter................ Depth................ x Disposal Trench—No. .................... Width..........--........ Total Length.....-..-------.---- Total leaching area.....-.---_----._.-sq. ft. Seepage Pit No--------------_---- Diameter.-- ------ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit.-.-------------.--. Depth to ground water............---......... 0-4 f14 Test Pit No. 2_-------------minutes per inch Depth of Test Pit..--.-..-.-----.--.- Depth to ground water....--.......--......... 9 ............-.........................................................................................................--......- ........ ----- •--------- 0 Description of Soil............................................................................................................................................................................ x W --- --------------------------------------------------------------------------------------------------------- ----------------------------- ............................................................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ••--------------------•••--•--•---•••••------------•-----•-••----------•---------------...•-----------------•--------------------------•-----------...-------•---.........--••--•---•--•••......•••-•-•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code— The undersigned further agrees not to place the system in operation until a Certificate of Compli n as een issued by the bo rd of health. s Signed ..... '�............ ... � ` _... = .....- 3' ..�..c�_5.... Dare Application Approved By ................. .... ----- ------------- Application Disapproved for the ollowing �earonr: -- - - _... .. ...... ......... .................. --------..........--------..................------------- Permit No. ......-.l-.�j- c ........ Issued - - r` Dace TOWN OF BARNSTABLE LOCATION tS ill- 61- SEWAGE# VILLAGE C° e h�e c' t9c l(e ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. YY11`a('0U✓t,D a�' Shc�l - 7 C SEPTIC TANK CAPACITY /0 O O LEACHING FACILITY: (type) —1 t`E' (size) NO.OF BEDROOMS N BUILDER OR OWNER f y PERMTTDATE: n _ (! COMPLIANCE DATE: f d ' 4L I Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on.site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a � li 31 �� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#ifiett#e of Grayliance THIS IS TO CER FY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ......................... - - -------- k�Ivr��j�Q. '------ --- - ---------_.--------.._..:------ -----. In tall --------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as descpbed in the application for Disposal Works Construction Permit No. �� .. .. 'i.............. dated . `..'7 ...- .7--.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT, HE SYSTEM WILL FUNCTION SATISFACTORY. DATE---------/4 ....... ....�� ...........- - - Inspector -- -- THE COMMONWEALTH OF. MASSACHUSETTS BOARD OF HEALTH Q'y� TOWN OF BARNSTABLE No... ......d.:./�j FEE......:b .. �i��n�tt1 ur�� �na��tr�n �rrmit Permission is hereby granted-----------........................ ......... to Construct an I or Repair) ( ) nditidk Sewa e Disposal System (� f" atNo .r ��{ -------------------------------------------------------------------------------••--- Street as shown on the application for Disposal Works Construction Permit No._. :J� . _.__ Dated......... . ----------.... DATE.................. ��C� ----------------...---•---- Board of Health C FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Ditivuutt1 lVurku Tomitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ? "` ., �.. Location i\ rcss or Lot No. � � = ' !° ------------------------------------- .__..... ,(� 11nOwner / ,� Address In staller Address U Type of Building r Size Lot.......:. ............Sq. feet .-.--Ex Expansion Attic ' Dwelling— No. of Bedrooms......... _______________________. p ( ) Garbage Grinder ( ) l a Other—Type of Building _______________________-___ No. of persons----------.----------------. Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow--------------------------------------------gallons per person per day. Total daily flow-------------------------------------,......gallons. WSeptic Tank—Liquid capacity-_____-.--_gallons Length---------------- Width---------------- Diameter---............. Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No--------_------------ Diameter._.--.---.._.----._. Depth below inlet-_--___-__.____-_--- Total leaching area.................:sq. ft. z Other Distribution box ( ) Dosing tank ( ) - 04 Percolation Test Results Performed by------------ ----------------------------------------•-•---------•-•-•---- Date--=....................--------•-•-•--- Test Pit No. l----------------minutes per inch Depth of Test Pit------------ ------ Depth to ground-4water..............4......... fs, Test Pit No. 2................minutes per inch Depth of Test Pit------------- ..... Depth to ground water........................ Description of Soil.................................................................... V -••••--••••••••-•-------------------••....•---•-••------------•----'••••------•--••-------.....-----• ----•----•--•••-•----------•••------••----•--•••--•-----•-•---•---••-----•••-•---•--'•-•------ x --••-- ------------------------------------------------------------------------------------------------------- --------- ••----... U Nature of,Repairs or Alterations—Answer when applicable-------------------------------------:....................................._____..._..._.._.t__. i -----------------------------•---------------....-------------•-----------------------•------------------•------------- ------------'t.......................................................... k Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli n has D een issued by the board of health. t� { Signed .... -- �........... ...... 7- 3© .5... Dace Application.Approved By .............. .............o,... .. . . ------------------------------------------------------------------ -- 11 =0 Application Disapproved for the following reasonr: ................... o '��� ................................ . . .......... ..... ........ . ...... ......-------------- ------..----------- ----------------------- ............ ....... .......-- - - p - (?ace Permit No. ...... /.. -------------- Issued ---------------------4�._-..� Dare