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Home My WebLink About0105 THOREAU DRIVE - Health 105 THOREAU DRIVE, CENTERVILLE '. A= 191224 r No. 42101/3 ORA ESSEL E 0 0 0 0 Commonwealth of Massachusetts Q® � - Title - e 5- Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 every page. City/Town 7/ State Zip Code Dateto of of in 3 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 filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Wayne Ar cursor-do not 6ctor Ault Name of use the return Inspector - key. Company Name PO Box 914 Company Address Hyannis MA — re" 01 City/Town State Zip Co Zip Code 508-775-1362 355 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR'15.000). The system: Passes ❑ Conditionally Passes ❑ Fa Q - zz ❑ Needs Further Evaluation by the Local A_p roving Authority C 1 co 7/15/2013 w ' ,- spector's re ------ Date r�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 un,der the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form: bs ace Sewage Disposal System Page 1 of 17 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 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 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): t5ins•3/13 Title 5 Official Inspection Forth: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 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 105 Thoreau Drive Property Address Owner Owner's Name information is Centerville MA 02632 7/15/2013 required for every page. City1rown 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 cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 — -- every 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. ❑ ® 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Thoreau Drive Property Address - Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 every 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? ❑ ® 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 l i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Thoreau Drive Property Address Owner Owner's Name information is Centerville MA 02632 7/15/2013 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7/15/2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: - - - Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 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 «M °p 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 every 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: installed 4/10/1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) riser to withon 6"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5'x5'x5' Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 every page. Cityrrown 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 35" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 3.5" Distance from bottom of scum to bottom of outlet tee or baffle 12 How were'dimensions determined? measuring 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.): 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 15ins•3113 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 M 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 every page. Cityrrown 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: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 °M 105 Thoreau Drive Property Address -- Owner Owner's Name information is required for Centerville MA_ 02632 7/15/2013 every 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 na Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Thoreau Drive Property Address Owner Owner's Name information is required for Centerville MA 02632 7/15/2013 _every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): 3' liquid in bottom of pit no signs of failure or vegetation 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Thoreau Drive Property Address Owner Owner's Name information is Centerville MA 02632 7/15/2013 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate.on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 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 105 Thoreau Drive Property Address — ---- --" Owner Owner's Name information is required for Centerville MA_ 02632 7/15/2013 every page. Citylrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Assessing As-Built Cards Page 1 of 1 LOCAMO SEWo, E RMIT we VILLAGEto -- a WILD - -- -- ^ - 5 DDRESS DATE PERMIT 155uED DATE COMPLI&MCE 1s5uEo : i o, 6� . Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Thoreau Drive Property Address ---— Owner Owner's Name — -- information is Centerville required for _ MA 02632 7/15/2013 w every page. City/Ton State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 18 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: Ground water plans at BOH ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: used ground water plans on file BOH 18' bottom of leaching pit 10, sepration 8 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Thoreau Drive Property Address Owner Owner's Name --- information is required for Centerville_ MA 02632 7/15/2013 _ every page. City/Town -- ---- _ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L ` Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Govemor Trudy Coxe Argeo Paul Cellucci Secretary U.Governor David B. Struhs 1 commiuioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM PART A _ CERTIFICATION - Property Address: I o 5 l oR E A u 3)R Iv E VIA C�.�T'ERV ILL>=' � P� M A QC N `a 7 19 9-1 1 Address of a r. Date of Inspection: nn (If different) Name of Inspector. R013Q k,-r G, Si moo 1 ,E� •Company Name,Address and Telephone Number- sty-1 oNoMoY CtCZ. CGiJTERV1Lt6� MA,, CERTIFICATION STATEMENT 14 I certify that I have personally inspected the sewage disposal system at this address and that the information 1 is accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the r ction and maintenance of on-site sewage disposal systems. The system: ZPasses Conditionallv Passes Needs Further Evaluation By the Local Approving Authority _ Fails R. E. SIMON/ASSOCIATES Consulting Engineers Inspector's Signature: Date: 241 Monomoy Circle —1 3—7 7 Centerville, MA 02632 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if appA&Id approving authority. P�ZH Or lyq 4 s INSPECTION SUMMARY: •c '�� ROBERT � EDWARD Check®B, C, or D. SI IV,ON No. 11192 ) A) SYSTEM PASSES: I have not found any information which indicates that the system violates criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurallv unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-SSW A 40 Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: X BJ SYSTEM CONDITIONALLY PASSES (continued) / \ _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): _.- broken pipe(s)are replaced-- — — r obstruction is removed distribution box is levelled or replaced. _ The system required;pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): •.r broken pipe(s)are replaced obstruction is removed w X\C FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection D] SYSTEM FAILS: . ,X\' I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 O 5 7_14o R1�:R v ._b R IV e 1 Owner. wp/ a "ev' :5 , C�VSTArSoiJ Date of Inspection: MA-R-A k a, )9Ck Check if the following have been done: ✓Pumping information was requested of th owner occupant and Board of Health. yL—�None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 9(1;_�G As built plans have been obtained and examined. Note if they are not available with N/A. ye S The$wilihy-. dwelling was inspected for signs of sewage back-up. Y92 The system does not receive non-sanitary or industrial waste flow ^{ The site was inspected for signs of breakout. N{g,$All system components, excluding the Soil Absorption System, have been located on the site. yp�The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. YF_5The sixcard location of the Soil Absorption System on the site has been determined based on existing informationar ow_-nd approximated by non-intrusive methods. Yj�_5 The facility owner( )were provided with information on the proper maintenance of Sub- Surface Disposal System. R. E. SIMON/ASSOCIATES Consulting Engineers 241 Monomoy Circle Centerville, MA 02632 (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION � Property Address: 10� 'T40QEP%U �RIVG $ C1S1-rTGRVIL1.E �",{ lA, Owner. Date of Inspection: N`a�c�t �a, 1gg1 FLOW CONDITIONS RESIDENTIAL• -}-. Design flow: gallons afa 5 u vA eA at Number of bedrooms: Number of current residents: Garbage grinder(yes or no): MQ Laundry connected to system(yes or no): 6�j Seasonal use(yes or no): 'V Q Water meter readings, if available:_ Last date of occupancy:--RR C S[N`r -'1(`'(%E COMMERCIAL/INDUSTRIAL: Type of establishment: . A Design flow:___pllons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: FRom -- PUMPE 8-14-57 System pumped as part of inspection: (yes or--na)_-�E tj If yes, volume pumped: —1iL--9a&nS "t'h t 5 1115 je r-t o 1%- Reason for pumping: 11'1 S P 1 C`i'1 n 1-4 -."A Tl PE F SYSTEM Septic tank/ ' it absorption system Single cesspool Overflow cesspool oY leaehthy P,fi Privy Shared system(yes or no) (if yes, attach previous inspection records, if any Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: Novse C�VIA :6y5tzv'tl bv'i (i- 1n . { 4?� Sewage odors detected when arriving at the site: (yes or no) p (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: 30 ,� Material of construction:]�ooncrete_metal_FRP—other(explain) Dimensions: 11(1Sl 1(1'15 , Sludge depth: 1 X" Distance from top of sludge to bottom of outlet tee or baffle: :L -1 Scum thickness: '11o'Yt e Distance from top of scum to top of outlet tee or baffle: -fro 1 V V QY1 Distance from bottom of scum to bottom of outlet tee or baffle: ' p Aviver Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) lyw S C U'lam — O'11 v U 4v,,o u Tlul GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal FRP_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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) � r\1tCow\�n2vN 1Y1.5 10.��1 cQj Y'eAe Yet 5 e-r e3v e Y 2c�c� acc e55 to t n_i 5 e CoV e Y'S (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I o'G TH o R EAv )�R)V E C E R-r E R V I L L E, MA. Owner. �/�f AL"C""(, C v S-T-AF S O N Date of Inspection: TIGHT OR HOLDING TANK_ 'YL.o'Yt JL (locate on site plan) Dsgth below grade: -- ... Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) ,�p Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal. evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER_-Vt o'VL? (locate on site plan) N , Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: / SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: 5 AS letxc�in ;� �occ�'� bv� ho� Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note co dition of soil, signs of hydraulic failure, level of ponding, conditio of vegetation,etc.) IAA - adv 2 0 wo — e e �'f�o►�. o ol S OW G> S iso CAL ' Qe 1 acl. roUVIA CESSPOOLS:_ (locate on site plan) t 1 I Number and configuration: `y 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(cesspool must be pumped as part of inspection) 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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 1 O S 7140 k12 A'v A AR%V Jjjj- CtV 1 1r PY1 ,LLL57 ► � (`-A l Owner. :5 C-11is F So 1-4 Date of Inspection: M a.-Rc�l 17 I M 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks + locate all wells within.100' '1 D •g C 0.�2 +0 I 2.0Y1 c(''2C� 1 eech t vlg �`�' it o) CY" CL. . septic f6k� o �as ew,er� v I screened �a'/ in r �Q.4Y cT �ovS� r i g a-rr VL9 e DEPTH TO GROUNDWATER Depth to groundwater: 6=feet method of-determination or approximation: CC:�V)n+ I v,-Rp Q� O 1.J a bo zaTta (revised 11/03/95) 9. R. E. SIMON/ASSUCUTES Consulting Engineers 241 Monomoy Circle Centerville, MA 02632 JOB NO. _w Robert E. Simon Civil Engineer JOB 241 Monomoy Circle Dare _ Centerville, MA 02632 _t BY -_- CUr.NT �'�Ati" app rox , 50. 5 gravy) d d� sTav%ce, �v-ow, 1 co ri�r e"t"e . p u �� SLV DyE 0V YVA SEPTIC i ANK apro>c. c-�-is�' ono scale �'0 9rovrd �� 10� ACME SEPTIC TANKS PRECAST ,CO., INC. Precast Concrete Products The products shown in the following three 2. Biological Treatment. — Solids and li- sections are Reinforced Precast Concrete Sep- quids in the tank are subject to decomposition tic Tanks. They meet the requirements for Sep- by.bacteria and natural processes. Bacteria pre- tic Tanks as being reasonably watertight sent are of a variety called anaerobic which covered receptacles designed and constructed thrive in the absence of free oxygen. This to receive the discharge of sewage from decomposition or treatment of the sewage building sewer, separate solids from the liquid, under anaerobic conditions is termed "septic," digest organic matter, store digested solids and hence the name of the tank. Sewage which has allow the clarified liquids to discharge for final been subjected to such treatment causes less disposal. clogging than untreated sewage containing the The Septic Tank conditions sewage so it same amount of suspended solids. may be more readily percolated into the subsoil 3. Sludge and Scum Storage. — Sludge is of the ground, thus protecting its absorptive an accumulation of solids at the bottom of the ability. Three functions take place within the tank, while scum is a partly submerged mat of tank to provide this protection. floating solids that may form at the surface of 1. Removal of solids. — Clogging of the the fluid tank. Sludge and scum to a lesser soil with tank effluent varies directly with the degree, will be digested into a smaller volume. amount of suspended solids in the liquid. As However, no matter how efficient the process sewage from the building sewer enters the sep- is, a residue of inert solid material will remain. tic tank, its rate of flow is reduced so that the Space must be provided in the tank to store this larger solids sink to the bottom or rise to the residue during the interval between cleanings: surface. These solids are retained in the tank, otherwise sludge and scum will be scoured and the clarified effluent is discharged. from the tank and may clog the disposal field. i INLET _ _ _ OUTLET iSCUM=II��t/ ` D SLUDGE CROSS SECTION OF A SEPTIC TANK i 1 - 18 f r , University of Massachusetts Cooperative i Issues in WATER UALITY Al Wtl } l(OURSEPTICSYST� � Se tics ` stem�Add tives Se tice Tank :Cleaners 2{�� `t" '�` � laf" �)*;�r " �t....�',��' '„'�V 'i"t�''';riP.. ��+`�,�„ Hazardous Household products 4 .ti, g'' Wat are . septic tank cleaners and P acid and so i m Septic System d u hydroxide may cor- e Y additives?How useful are they?What rode the concrete in the tank,cesspool is their im act on the environment? Additives fall Ir1t0 three p cateories: or seepage pit. When properly designed, installed g In concentrated forms,these chemi- and maintained,on-site septic systems cals should be handled only by profes- ma function trouble-free for man 1• Yeast,bacteria,enzymes y y sionals.They are very caustic and may years.Some systems,however,develop Manufacturers of these products usu- lead to personal injury or damage to problems due to outdated designs, im- allay recommend that you regularly add your septic system. proper installation or improper mainte- these products to the septic system via Hydrogen peroxide.should be used nance.The owner of a failing system is the toilet. They are harmless to the only in specific soil conditions.If used faced with several choices, most of environment and of little value to improperly,it will make leaching prob- them expensive. your system. Sewage naturally con- lems worse rather than improve soil tains vast amounts of east and bacte- ria b li that maintain themselves permeability. 'ty.without These products bring temporary (a What do Septic System need for supplements under normal few months) duct frombring temporary ged leach- inga Additives claim to do operating conditions. area and do not address the basic for your septic In fact, use of these products:may .� damage your-septic system. Research cause of the.failure.At best,they should system? be used only in emergencies thereby has shown that some of these products Homeowners are often tempted by the. may cause the production of methane. allowing more time to consider re- seemingly low cost of septic tank addi- This gas bubbles through the septic pairs that truly address the cause of tives that claim to be alternatives .to , tank and refloats sludge particles that the failure. costly repairs.Some 12,000 septic sys- flow into the leaching area,and then Inorganic compounds may affect tem additive products.on the market may end up clogging the soil. groundwater by increasing the concen- claim that they save maintenance cost Yeast,enzymes and bacteria are also_ trations of salts or metals(such as cop- or prevent failures. They claim"to do not required to restart your system after per) in the water that flows out of the this,for example, by regularly feed- you have had your tank pumped.There septic tank. However, given the total ing your system with bacteria or yeast, are enough microorganisms in the tank volume of water used in the average or to fix an already existing problem to perform that role. system,these effects can be considered by. reopening or unclogging your negligible under normal conditions. leaching facility. 2. Inorganic chemicals 3. Solvent-based, Inorganic septic system additives,such -biodegradable products Wily is there concern as sulfuric acid, sodium hydroxide or about the use of these hydrogen peroxide, are used to restore Compounds, such as methylene chlo- productS? a clogged leaching area, (the primary ride(MC)and trichloroethylene(TCE), cause of septic system failure). These were commonly used as degreasers There are three concerns connected with additives destroy the excessive organic. or drain openers.They are hazardous the use of commercial septic system matter that has accumulated around the substances. TCE is a carcinogen. additives: leaching facility keeping the wastewa- Because of their potential to con- e using them may harm your system; ter from getting into the soil.. They taminate groundwater, manufactur- • should be applied directly to the leach- ers have removed TCE and MC from using them may contaminate ground pp y applying water; in their products. Before an g facility. Application through they septic tank dilutes the product and re- product, the user should read the la-using them may be ineffective,but will duces its effectiveness. Also, sulfuric bel to ensure that these chlorinated discourage you from investing in mainte- hydrocarbons are not present. nance and repair when needed. University of Massachusetts,United States Department of Agriculture and Massachusetts counties cooperating. Cooperative Extension offers equal opportunity in programs and employment.CR-0368:1OM-12/94 Economic Legal Issues however,is quick to point out that this Considerations Connected With Septic does notconstitute an endorsement of the product's effectiveness. Before considering use of an additive, System Additives: you should compare its price with that As of.April 1, 1995 it is illegal to use Additional Information of regular septic tank pumping.Pump- or recommend septic system additives More information on environmen- ing every three to five years may be y unless they are on a list of state ap- tall safe and •cost effective septic less expensive than using additives y p p g proved products. The criteria used :system management methods may be over the same period. Most important, for approval of products,is that they ` obtained by contacting-your local Board pumping has been proven to work by do not harm the system's compo of Health,.your regional DEP office or extending the life of your system.Most nents or function and do not adversely nearest UMass Extension Center. additives make claims that cannot be affect the environment. The state, substantiated. . .HowA do Hazardous Honus' h A sp P a M d roducts Affect Your System How can I dispose ,of household Chlorine bleach 'Salt"brine froiii water softeners chemical products to a manner that Research shows that it takes sev Dumping the regeneration brine . does not harm the septic system or the eral gallons of liquid .household ti5 from water softeners into your septic . environment? " bleach to destroy'all the bacteria m system should have"no adverse effect Many owners of homes,"with the septic tank.The bacteria popula- r- on the life of microorganisms in your on-site wastewater systems are con- tion recovers its original strength tank but may shorten the life of your, cerned about how,their systems will, within 30 hours of normal. septic leaching facility if it is in clay soils. be affected by the use or disposal of system operation. This means that ' hazardous household products such -normal use of household bleach has Do not use your septic system as bleach, laund_ detergents, left- as a household hazardous rY g `no negative effect on your system. over paint thinners, drain cleaners waste depository: or pesticides. Disinfectants" While there is little reason to worry Similarly,it takes about five gal- about normal use of the above sub- Ions of Lysol*to destroy the bacteria stances,' you do not want to dump What About Home population, with a similar recovery leftover liquid floor wax, 'furniture Cleaners and time of a day and a half. polish,pesticides,paint thinner,auto- . Detergents? , N motive liquids such as antifreeze,brake Crystallized drain cleaners .m fluid or battery acid down your drains. Harmful effects of ordinary house- ".However,it takes only one cup of While they do not harm your system's hold chemicals on septic system op- crystallized.drain•cleaner to destroy ;,performance, `they do pass right eration are often overemphasized. the bacteria in the"septic tank and the through it into the ground water sup- Home care products designed to go recovery time is three days. : ply and could end up in your down the drain, including soaps, de- , tergents, bleach, disinfectants and Soaps and detergents 3 neighbors drinking well. .. To maintain your system:keep your drain cleaners, when used at the : These substances used m normal n 'leach field free of brush,and trees.Do recommended rate,' will not ad- amounts do not"harm your'septic not drive or park over any part of your versely affect septic system perfor- :system. Powdered detergents con !-system. Have your tank pumped mance or the environment.The sep- tarn.filler substances that do not ;regularly and do not use your sys- tic tank, when _properly sized and settle out in your tank. Liquid de- . tem as a trash can.Follow the simple maintained, acts as a buffer against. aergents do not burden the tank in maintenance'`rules described' on most"negative impacts. this manner. ` d, 'other fact sheets.` . -..• _ *Lysot-is a brand name for the disinfectant"used in the research. Its use-does not constttute an,endorsement... This material is based upon work supported by The Massachusetts Environmental Trust.Issued in furtherance of Cooperative Extension work,Acts of May 8 and June 30, 1914,in cooperation with the United States Department of Agriculture.Robert G.Helgesen,Dean and Director,Cooperative Extension,University of Massachusetts.The Cooperative Extension System offers equal opportunity in programs and employment.Prepared by Gisela Walker, Extension Specialist;David Gordon,M.S.;Peter Veneman,Ph.D. LOCQTIO SF-\,NJ E RMIT U0. A VILLAGE INS AL _ E DDRESS 5UILD 5 1.! E DDRESS a DL17E PERKA T ISSUED D s.TE COMPLI &&ICE ISSUED : �s _ � ,e� �2 �� T't;e s moo.._.... .._"_.... Fz�$............................ THE COMMONWEALTH OF MASSACHUSETTS !L BOARD OF/� HEALTH !..1.. O F......-.'lc�.T =V.J�Di�h. .........- Appliration -for Di-qposal Worbi ( om4rurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Lyc on-Address /�, or Lot No. --- -= = = C..L/ �✓ � ..-------- Owner Address a �� -� ----- --- --.._..-•-•----•--•-•= . --------------------•--- Installer Address Q Type of Building Size Lot.l__��.._� q.....Sq. feet Dwelling—No. of Bedrooms..............................._------_-----Expansion Attic ( ) Garage Grinder ( ) p`-i Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures _________________________________ Q -•--•----------------•- ----------_------------• ----------------------------------------------------- - W Design Flow.............�v.......................gallons per person per day. Total daily flow------------------------------------------..gallons. WSeptic Tank—Liquid capacity-_AOCkallons Length................ Width---------------- Diameter................. Depth.-..--.---.----- x Disposal Trench—No_____________________ Width-------------------- Total Length.................... Total leaching area....----------------sq. ft. Seepage Pit No----------{--------- Diameter___..__..4__'_l_Depth below inlet.................... "Total lea hung area-_---.._-.--__-__sq. ft. z Other Distribution box ( ) Dosing tank ( ) 3 Po a-6 PG clt(Vc'? - aPercolation Test Results Performed by--------------------------------------------------------------- -------- Date_-_-_-___-___-----_----•-----------_.-.. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-----------.--.--.------ fA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------__--__._--_---- 04 ------------------------...........................................................................................................................I Description of Soil----, `Y --------------�-•----•-_,r.6__-------Jam----' --- 15�e--------------------------------------- U ----------------------•-------...-•--- _SL`lll��'-` ---------�-'.y-- :. _:_e --- ----------- ------------ w x ------------------------------------ -•------- --------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applica.ble.-.-------------------------------------------------------------------------.................... -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The under geed further agrees not,to place the system in operation until a Certificate of Compliance has be is by t o rd of heal h J-.�y- 7 S Signed.................................. ------==-=-••---- r---=--•-•-•-•--•--------- ------------- Date Application Approved BY .-tz'�•-_ ---- t*--- 7 Date Application Disapproved for the ollowing reasons----------------•----------------------------------------------------------------------------••---•-•------------ -------------------------------------------------------------------------------------•-•------------------------------------------------------------------ ----------------------------------- � - Date ,J �//� Permit No.•••--7- -------•-----------------•--------___- issued.......1l .................... Date No. --••- FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -------.OF Applirtttion -for Ui�pu.gttl lgorkii Tomitrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 7 15 r d .• o Address C 7f - r :._.... ,a "Owner / d r r� Installer Address UType of Building Size Lot--- _ _Q.........Sq.,feet Dwelling—No. of Bedrooms_________________________ _-_______.Expansion Attic ( ) Garbage Grinder ( ) __________ No. of ersons_-_____•-__________________ howers ( ) — Cafeteria ( ) Other—Type of Building __________ p S ' a' Other fixtures ____________________ W Design Flow............T gall°bns per person per day. Total daily flow---------------------------------------------gallons. W4 Septic Tank—Liquid calnclty____________gallons Length---------------- Width................ Diameter---------------- Depth.__._____.----- xDisposal Trench—No. .............f_GI,vVidth....._.............. Total Length---_-------_----- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area---------------__.sq. It. z Other Distribution bfx ( ) D6-itiffank ( ) aPercolation Test Results Performed by---------------_------ ----.------, _r!? --E----�A--rt�;*f_ (Date------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._.___.._-_-.____.-__-- rs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_--_.___________-... . Description of Soil.__ '•' x ------------- --------- ----------- ......-- -`/-----------0!-e � ---- ------ U Nature of Repairs or, Alterations—AT1sW'&f.when applicable...____•';-.___:_._'_____________S.__.:__.__.______ __._.__..._..___-_...__.....____.____..._.... - ---------------------------------------------•--------•---------------•--------••---------•---••----------•--•-••---•-------•--•-----------------------•--•-------------------_--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The under tied further agrees not to place the system in operation until a Certificate of Compliance has been iss by tl' oii d of hea lAi64o Signed.'.':. Date ApplicationApproved By---------------- -----------------------------------------..........•----------•-------- ..............- o.F.-- ----- Application Disapproved for the owing rettsons-................................................................................................................ ., Date Pertnit'No. -_ .---•----•------ Issued.------•------------------------•---•------..._.. Date ,.tom. e.._ `r+y THExCOMMONWEALTH OF MASSACHUSETTS �G BOARD OEh J-14EA , :. .:. .............................OF............................. (Intifirate of TwOmphaurr THIS IS= IFY, Individual Sewage Disposal System constructed ( ) or Repaired ( ) a .----------•----------------•-•--•-•----•-------•---------•----------•-- has been installed in accordance with the provisions of Article"')kJ/ The State Sanitary Coda-s:0e�tr+bej m'% the application for Disposal Worket✓onstruction Permit No......................................... dated............_................................... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE_ • Inspector z A. THE COMMONWEALTH OF.MkSSACHUSETTS ..........................................OF................................................................................ .... No------_--_----------- FEE........................ 's+ Permission is 4ereby granted.......................... ...-- --... ... ---•--•------•--••ww7czz•----•--•-•-•-•----- to Construct ) or it ( ) dytptiv6ew � dal S stet�ri t'� t l'- E Y atNo. •----------•----•---••--.---------------,...--- r .... = . --- . -- .. ,. Stiat*,/ .,as shown on the•application for Disposal Works Construction Per "Y d (• #' ..__...--.... Board of Health•--••-•----•- - --•-••---•-•-----•-- � • DATE..................9L.ala --- ----------- -------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �,t;�, • _ _ u, CHARLES N. SAVERY , INCORPORATE® 712 MAIN ST HYANNIS , MASS. PLAN SHOW,WI Nq LOCATION OF BVIL.DIt-AG I CENTERVILLE . A R .N S T A B LF— BASS.. . FO R ALAN E S MALL INC, SCALE 1 = 60' MARCH !"h 1915 �I % �f 3 �. ( �4-2 43 Y 101. IV LOT ?9 2t,665 S.F .o 9 m S® ? 8 N � _ R - - ¢.. �o QAA � r X% 'yO IN OF hereby certify that the building exists �� ROBERT on the ground as shown on this plan and �J P. RUNIKI$ « �o is in accordance with the zoning n req 'rements qj the Town of Barns able / 0:8UR14 Registered Land Surveyor II 'I CHARLES N. SAVERY , INCORPORATE® 712 MAIN ST. HYANNIS , MASS. , PLOT PLAN 5HOWI NOR L.00Alp10I4 OF 5UIL.OING CENTERVILLE . A R N S T A B L NASS. FO R ALAN E, SMALL INc. j SCALE ' 4 " = GO' MARCH I7� 19? 5 ' j ! _ 4-Z 4.3 I LOT 79 co U1 0� i a 8 J' 78 N Rd o O S G � r D N I6. x ®A,(o XX 0F hereby certify that the building exists /o y ROBERT � n on the ground as shown on this plan and ;i RUNIKI9 / P. - Q is in accordance with the zoning No.8420 fry req irements oJ the Town of Barnstable \�Fc,,T�a�op r bURV Registered Land Surveyor 7223.E