Loading...
HomeMy WebLinkAbout0074 THREE PONDS DRIVE - Health (2) 4-Three.ponds Circle Centervillt A= 173 —071 I S M E A D No. H163OR UPC 10259 smead.com • Made in USA e- y Commonwealth of Massachusetts 3-Q.�.� lugTitle 5 Official Inspection ForseSubsurface Sewage Disposal System Form-Not for Voluntary Asses'sments 74 Three Pond's Drive Property Address Owner Kaufman information is Owner's Name required for every Centerville Ma page. Cityfrown 02632 9/23/17 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in an way. Please see completeness checklist at the end of the form. y Important:When filling out forms A. General Information on the computer, S' I u use only the tab 1. Inspector: key to move your cursor-do not Chad Hathawa use the return key. Name of Inspector H.P.S. Company Name ' P.O.Box 151 �I Company Address ' Forestdale City/Town Ma 02644 774-274-2581 State Zip Code Telephone Number 12866 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 ins Title 5(310 CMR 15.000).The system: pector pursuant to Section 15.340 of ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority InspNctors Sign awe 9/23/17 Date The system inspector shall subm' a c9 y of this inspection report to the Approving Authority(Board of Health or DEP)within 30 da mpleting this inspection. If the system is a shared system or has a design flow of 10,000 gp 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 J ` Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Three Pond's Drive Property Address Kaufman Owner Owner s Name information is required for every Centerville page. Cityl I own Ma 02632 9/23/17 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Septic in good working condition 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 state determined I statements. "ease 9 If n p explain. of 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 lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Three Pond's Drive Property Address Kaufman Owner information is Owners Name required for every Centerville Ma 02632 page. City/Town 9/23/17 State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health a roval if Pumps/alarms are repaired. pp 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 lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Three Pond's Drive Property Address Kaufman Owner Owner's Name information is required for every Centerville Ma 02632 page. City/I own 9/23/17 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: D1 S ystem 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Three Pond's Drive Property Address Owner Kaufman information is Winer s Name required for every Centerville Ma page. Cityrrown 02632 9/23/17 State Zip Code Date of Inspection B. Certification (cont.) Yes No [3 ® 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the System in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official inspection Form: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 74 Three Pond's Drive Property Address Kaufman Owner information is Owners Name required for every Centerville page. Cityt I own Ma 02632 9/23/17 C. Checklist State Zip Code Date of inspection 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 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 6 of 17 Commonwealth of Massachusetts lugTi • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Three Pond's Drive Property Address Owner Kaufman Owner's Name information is required for every Centerville page. ClY I own Ma State 02632 — 9/23/17 YIPCode Date of inspection D. System Information Description: Number of current residents: seasonal for ----Does residence have a garbage grinder? 10 weeks Is laundry on a separate sewage system?(include laundry system inspection Yes ❑ No information in this report.) ❑ Yes ❑ No 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: seasonal Commercial/Industrial Flow Conditions: Date 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•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System For-Not for ol Form lop Voluntary Assessments 74 Three Pond's Drive Property Address Owner Kaufman information is Owner s Name required for every Centerville page. C6/ own Ma 02632 9/2�—Date—ao'—�f'lfnspe—ct�ion—�—� 6• System Information (cost.) State Zip Code Last date of occupancy/use: Other(describe below): Date ro a was used seasonally for 10 summer weeks for the last 10 years. General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? If yes, volume pumped: 1000 ® Yes ❑ No gallons How was quantity pumped determined? tank size ,`i Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, If any) Innovative/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 Masi Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection a Subsurface Sewage Disposal System Form Form -Not for Voluntary Assessments ,M 74 Three Pond's Drive Property Address Owner Kaufman information is Owners Name required for every Centerville Ma page. QW-rown 02632 9/23/17 Date State Zip Code of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 31 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 30' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 218" feet Material of construction: ®concrete El metal ❑fiber lass 9 ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate Of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 41# t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Form tary Assessments 74 Three Pond's Drive Property Address Kaufman Owner 's information is Owner Name required for every Centerville page. Cityi I own Ma 02632 9/23/17 State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3^ Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? tape and sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural inte ri , liquid levels as related to outlet invert, evidence of leakage, etc.). g tY pump every 2-3 years as maint. to protect leaching. tees in place no visable concrete decay cracks or leaks of tank 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: t5ins•3H3 Date Title 5 Official Inspection Forth;Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection FOl"n1 Subsurface Sewage Disposal System Form-Not for Voluntar y Assessments ugl 74 Three Pond's Drive Property Address Owner Kaufman Owner's Name information is required for every Centerville page. Citylrown Ma 02632 9/23/17 State Zip oCde 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 El metal fiberglass 9 ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ElNo 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form Not for Voluntary Assessments e 74 Three Pond's Drive Property Address Kaufman Owner 's information is owner Name required for every Centerville page. C61 own Ma 02632 _ 9/23/17 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.): Dbox was camera inspected becouse of no risers. Dbox is clear of cagy overs Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Ala rms 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 Form;Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Form M °�e 74 Three Pond's Drive Property Address Owner Kaufman Owner's Name information is required for every Centerville Ma page. Cityfrown 02632 9/23/17 State Zip Code Date of Inspection D. System Information (cont.) Type: ® 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: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leaching pit has riser in place top of pit is 6 feet deep. Pit was dry at time of inspection with no sidewall staining. Leach pit in good condition I 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 t5ins•3/13 Indication of groundwater inflow ❑ Yes ❑ No 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 74 Three Pond's Drive Property Address Owner Kaufman Owner's Name information is required for every Centerville Ma 02632 page. City,I own 9/23/17 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 Subsurface Sewage Disposal System F t Form or Voluntary Assessments �` 74 Three Pond's Drive Property Address Owner Kaufman information is Owners Name required for every Centerville page. City/Town Ma 02632 9/23/17 D. system Information (cont.) state Zip Code Date of Inspection Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including 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: ties to ® hand-sketch in the area below ❑ drawing attached separately i fi 0 a6'e 3 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 0 Commonwealth of Massachusetts ' � Title 5 Official Inspection Subsurface Sewage Disposal Form System Form-Not for Voluntary Assessments �e 74 Three Pond's Drive Property Address Owner Kaufman information is Owner's Name required for every Centerville page. Cityrrown Ma 02632 State 9/23/17 cont.) D. System Information ( Z'p Code Date of Inspection Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 26'+ e Please indicate all methods used to determine the high groundwater elevation : Obtained from system design plans on record - If checked, date of design plan reviewed: town GIS ma s Date 0 Observed site(abutting property/observation hole within 150 feet of SAS) _ ❑ Checked with local Board of Health-explain: ❑ �. r Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: area of se tic el. 74-76. Pond el. 49.62. bottom of leachin e1.64 ~ , r: yl Before filing this Ins tsins 3/13 pection Report, please see Report Completeness Checklis • ton next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection lug Subsurtace Sewage Disposal System F�-Not f°n �orm oluntary Assessments 74 Three Pond's Drive Property Address Owner Kaufman information is Owner's Name required for every Centerville page. City/Town Ma 02632 _ 9/23/17 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 5 � y , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -I Li rt1r��e lc. P>C) Cyr_ Property Address _ b C-CWQ-s t V Owner Owner's Name co(q y� N8- 6 ? 041Z-1 101 information is required for every page. QWrown State ZIp Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered In any way. -y>9 important A. General Information Q When filing out /�3 Q 0/- / forms on the computer,use 1. Inspector: onlythe tab key to move your ` 1�a5 1!I�_ Q�e Cursor-do not Name of Inspector kuse the return t� S Pi i Company Na � ro �� Lxv Company Address Itl City/Town state Zip Code telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addrf and thdMe information reported below is true,accurate and complete as of the time of the intoction.TU inspection was performed based on my training and experience in the proper function and no�ttenance of on bite sewage disposal systems. I am a DEP approved system Inspector pursuant t tion M340 6f Title 5 310 CMR 15.000).The system: fi : Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the local Approving Authority bg1z [ o� Ins'ector Synature 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. t5insp.doc•06% Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name required for —Q—�c 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: [�J 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: -- I B) System Conditionally Passes: ne or more system components as described in the"Conditional Pass'section need to be r aced or repaired.The system,upon completion of the replacement or repair, as approved by the rd of Health,will pass. Answer yes, o or not determined(Y, N, ND)in the❑for the following;ank me . If"not determined," se explain. ❑ The septic tank metal and over 20 years old*or the septic tank( er metal or not)is structurally unsoun exhibits substantial inflftration or exfiftration failure is imminent. System will pass in on if the existing tank is replaced with complying septic tank as approved by the Board of Ith. *A metal septic tank will pass ins ion if it is struct airy sound, not leaking and if a Certificate of Compliance indicating that the tan 's less than 0 years old is available. ND Explain: ❑ Observation of sewage b kup or break out or high static water le in the distribution box due to broken or obstruct pipe(s)or due to a broken, settled or uneven . ribution box. System will pass inspection if( approval of Board of Health): ❑ broke pipe(s)are replaced ❑ obstruction is removed t5tnsp.doc.08M T tle 5 Officiat Inspectbn Form:Subsurface Sewage Disposal System•Pepe 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface- Y� �S"ewage Disposal System Form-Not for Voluntary Assessments -I 1 LI �Ce-e ���� i`I—. Property Address Owner _ information is required for qy�1 A 0 Z632 ©L4 1 zL l V� every page. Cfty/Town State Zip Code Date of Inspedion B. Certification (cont.) \Expt Conditionally Passes(cont.): istribution box is leveled or replaced ❑ The system requ pumping more than 4 times a year duet roken or obstructed pipe(s).The system will pass in on if(with approval of the Board of ealth): ❑ broken pipe(s) re replaced ❑ obstruction is re ND Explain: C) Further Evaluation Is Req by the Boa of Health: ❑ Conditions exist which uire further evaluation the Board of Health in order to determine if the system is failing to rotect public health,safety the environment. 1. System will p unless Board of Health dote as in accordance with 310 CMR 15.303(1)(b)th the system is not functioning In a m nner which will protect public health, safety and t environment: ❑ esspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetat etland or a salt marsh 2. System will fall unless the Board of Health(and Public Water S plier,if any) determines that the system Is functioning In a manner that protects a 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. t5insp.doe•0801 Title 5 Official Inspection Form:Subawface Sewage Disposal System-Page 3 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _-ILA ��ree- Property Address Owner nweS Owner's Name information is required for every page, own State Zip Code Date of Inspection B. Certification (cont.) C) er Evaluation Is Required by the Board of Health(cunt.): ❑ The tem has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fro private water supply well*'. Method used to determin istance: *"This system passes if the well water anal performed a DEP certified laboratory,for coliform bacteria indicates absent and the presence of a n'a-nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure 'ens a triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You m s 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 cogged 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 099 P ❑ d Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ d Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp.doc•08M Title 5 Official Inspection Form:Subsurface Sewspe Disposal System•Pape 4 of 15 I � ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal)System Form-Not for Voluntary Assessments prty Add f� S Owner Owner's Na Q 1 inforrnallon is evy page. Citylrown Sta Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ Ed Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ C� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ L7 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 f&il . 1 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 desi flow of 10,000 gpd to 115,000 gpd. For large system , u must indicate either'yes'or"no"to each of the following,in addition to the questions in Section D. Yes No �. El El the system is within 40 of a surfaceng water supply ❑ ❑ the system is wi 00 feet of a tribut� a surface drinking water supply ❑ ❑ th em is located in a nitrogen sensitive area m Wellhead Protection rea—IWPA)or a mapped Zone II of a public water supp I If you have answered"yes"to any question in Section E the system is considered a signific nt-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. Mnsp.doe•08M Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �`li-1 `T�re251 Property Mdress Owner (���eS I Owner's Netne information is required for every page. City/Town State Zip Code Date of Inspedion 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 ❑ �J 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? ❑ d 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 NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? [� ❑ Was the site inspected for signs of break out? L1 ❑ 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 f been determined based on: L�J( ❑ Existing information. For example, a plan at the Board of Health. d ❑ 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)1 t5insp.doc•08106 Title 5 Olfidal Inspection Forth:Subsurface Sewage Disposat System•Page 6 of 15 C_\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` ILA 7�(-e ?ofclS Ci c- Pr�es Owner Owners ame 1�1 /�fl� 1 information is c Q. I ��1 l\-�— L v Y ' ® � l2� 0� required for every page. Citylrown State ZIP Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ` 3 Number of current residents: n Does residence have a garbage grinder? ❑ Yes d No Is laundry on a separate sewage system?IN yes separate inspection required) ❑ Yes M No Laundry system inspected? ❑ Yes d No Seasonal use? d Yes ❑ No Water meter readings,if available(last 2 years usage(gpd)): Sump pump? ❑ Yes No Last date of occupancy: ^A Date CommercialAndustrial Flow Conditions: V Type of lishment: Design flow(based o CMR 15.203): Ganon r day(gpd) Basis of design flow(seats/person , etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pre ❑ Yes ❑ No Non-sanitary waste di s rged to the Title 5 system? ❑ Yes ❑ No Water mete adings,if available: Last date of occupancy/use: oats Other(describe): t5insp.doe-08= Title 5 Official Inspecdon Forth:Subsurface Sewage Disposal System-Pape 7 of 15 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments Property Address es� Owner owners N me _ �� (� Rom/information is (� „`n�f-v 1 �\ /V�T1 V C,b3 Z ©q I-Z-q Q-7 required for V`-Y � every page. CityJrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: �e Was system pumped as part of the inspection? ❑ Yes � No If yes,volume pumped: gallons How was quantity pumped determined? 1 Reason for pumping: - 11 '�G�L� C) 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if kn wn)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes [/No t5insp.doc•08/08 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 8 or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments --ILA i?p n�S C"c. P/°�rty Address co'-Qes Owner's t� i Name \ f� �` 1 ` ` r I information is (' eN \Q'-Q c\\� r v 0%� Q. A 12-`-( ( 0 Pl required e- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: \- [�cast iron ❑40 PVC [�other(explain): �C ' 3 C' 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 ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: �ll Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Y-v o(\C- 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? �e t5insp.doc•08M Title 5 Of idat InspeWon Forth:Subsurface Sewage Disposal System-Pape 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -14 T\Y-ee. G'c- Property Address Owner owner's N me i�uMormetdofo �Owner's dam OU3Z OL4 12910-7 every page. City/rown 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 outlets invert,evidence of leakage, etc. C-0\1 S or\ rXSe S• Grease Trap(loca on site plan): Depth below grade: feet Material of construction: ❑concrete p metal ❑fiberglass lyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outie ee or baffle Distance from bottom of scum to om of outlet tee or baffle Date of last pumping: Date Comments(on pumping r mmendations, inlet and outlet tee or baffle con -ion, structural integrity, liquid levels as related t outlet invert,evidence of leakage, etc.): Tight or H ding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth elow grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): t5insp.doc•08f06 Title 5 Official Inspection Form:SubauAace Sewa ge Disposal System•Pape 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro arty Address C'o..1`l e r Owner rsm Na information is required for �`(1 %�, `\� 12- 4 I o 3 4 every page. City/Town State Zip Code Date of Inspedion D. System Information (cont.) Ti t or Holding Tank(cont.) Dimension . / Capacity: gauons Design Flow: gallons per day.-,- Alarm present: es ❑ No Alarm level: Alarm 1 rking order. ❑ Yes ❑ No Date of last pumping: Date Comments(conditi alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 00 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.): e� Ny'\6 80 r G.." D LLGv Pum"1working ate on site plan): I Pumpsder: ❑ Yes ❑ No Alarmsder: ❑ Yes o t5insp.doc•08M Title 5 Officiel Inspection Fonn:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -TLt �-��� ?ora r Property Address Owner Owners N�me iequired on is Cam; \ �!�-.�` f\� required for l AA- O263 z O e-A (z..�--� t O 1 every page. CRY/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: If [� leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): ; - 1 b pJe-- r� se�s t5insp.doc•08ft Title 5 Official In specfion Form:Subsurface Sewage Disposal System•Pam 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -I L4 Twfee ?ov\�S cr_ Property Address Owner Ow er's Nameinforimation is , 1 ^� Lf required for every page. City/Town State Zip Cbde Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Nu r and configuration Depth—to of liquid to inlet invert Depth of solids er Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs hydraulic failu , level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments( e condition of soil, signs of hydraulic failure, level of ponding, conditio of vegetation, etc.): t5insp.Qoc•08M Title 5 Official Inspection Form:Subsurface Serape Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address owner owners Name reqLdred for every page. City/Town State Zip Code Date&inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. � t3 0 0 l 2 l5urep.doe 08M Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape U of 15 r t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name inforrnation is every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: aver to a�- .❑ Check Slope -' 3O i r h i C�� 'knee-- ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water 25 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: i You must describe how you established the high ground water elevation: T:mY\ o 'S��o� � ctn 1i t�r�e b© �\®m o �p 'SS is 12t01T'- 6 m fA a\wd ±C� ?M6 v� r�o�n S. IJes ex-\ t5insp.doc•08W Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 15 of 15 �� TOWN OF BARNSTABLE LOCATION [� 1 Y\( Pod 1(—. SEWAGE# \ VILLAG4 ASSESSq R'S MAP&PARCEL NAME&PHONE NO. SEPTIC TANK CAPACITY k O ��a LEACHING FACILITY: pp t 2 r (type) � A (size) A�ti7 NO,OF BEDROOMS OWNER C` CA. DATE: O �` ��� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY r� � a i ;- �161 3, 2 LOCATION . SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS C,"c-upvo lea 8 U I'L D E It OR OWNER' r DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED r *i ��,t�t- 3 t� �� ,� v .. r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HE LTH .....OF........ ............................... Appliration for Bi_qpusal Works Cnnnitrnrtinn rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ~ System at: .....� .............` ..•... .O.I�-1-S.. .......�..... `��t. . -� .............................. '. • Locaa�t�w. Addre s or Lot No. Qv 1�5 tyV .r................. ..........--...................................................................................... O/wlner Address �......t4c,—.JeY. ........:........ ..•-------•-...................... --------.....-•---......-------•-•-••--- Installer Address d Type of Building Size Lot.. _ AIM.SF-Sq. feet U Dwelling—No. of Bedrooms..............?..........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures ._..__. • W Design Flow......_ _____ �.�......•__gallons per person per day. Total daily flow.......33.0........................gallons. WSeptic Tank—Liquid capacit/® ___gallons Length................ Width................ Diameter................ Depth................ x ,Disposal Trench—No.._._..I_._....... Width_._..___6.____._.. Total Length____--d........... Total leaching area..A k.......sq. ft. 3 Seepage Pit No............. "__. Diameter........--_...... Depth below inlet........----...... Total leaching area..........-_----sq. ft. Z Other Distribution box (11*01 Dosing to ( n) '-' Percolation Test Results Performed by._. l lec �.rt . ryc�,i. �t'�'�eo ............ Date. �....._...._.. Test Pit No. l...AA-0 minutes per inch Depth of Test Pit____________________ Depth to ground water--_____-__----_----_--" Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ •--•---------------------------------------------- .........................................................-............... Description of Soil---...P_---'. ......._.1��.�1r ?.... ?[.....s.—VIO_Pi- ---------- --f -1 ..�__ R'[x --..---- - -.0 . x U W ------------------------------------------------------------------------------ ....................................................:.....................-............................................ VNature 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 iITi LE 5 of the State Sanitary Code— The under/nef -tl:er agrees not to place the system in operation until a Certificate of Compliance has be i su by the th.Signed••.. --� ---- ------------- ................................ ApprovedBy............. .:.��..-----------------.................-----•------------•-•--............---- ...............f/'''-��•--- Date Application Disapproved for th following reasons---------------------------------------------------------------------------------------------Da.----•..._....... ----------•---•----•-•----------------------------•---------------------------...........------•-••------•--•--•--------•-•-------•-•-••---••--••-••--••--•-••-•----•--•-----•--------••-•---•--•-•---- Date Permit No......7.... Issued.... =-✓ll-7.71=-------•-------•-----....._. Date „w - ...... ..... FEE....... ..... _ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliraa#iun for UiipusFal arks Tonutrur#iun rrani# x I Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposa61, System Ia't:' :- ....pj�tads.zn. ................r ......................- Locatwn•Addref s or Lot No. ---•............. ..................................................... w O/w�ner Address Installer Address Pq U Type of Building Size Lot__ _12q��?.. Sq. feet Dwelling—No. of Bedro .................................. Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ... ---------------- --- -----------------------------------------------•.................. ....... •--------- ____........ W Design Flow______._ _ ....� ..._.gallons per person per day. Total daily flow_______ _ a........................gallons. g -- -- g P P P Y• Y � - WSeptic Tank—Liquid capacityA0 _..gallons Length---------------- Width__._`......... Diameter---------------- Depth................ x Disposal Trench—No-------/�_.......... Width........A.......... Total Length.._._.4?.._........ Total leaching-area.. A�.......sq. ft. Seepage Pit No.............' ... Diameter.......`”'________ Depth below inlet........:!!!y..... Total leaching area_________ ....sq. ft. z Other Distribution box ( Dosing to ( ) W Percolation Test Results Performed by___ � r _�._ � �t_2C�?C?L____ _____________ Date`.VVtf-Z-19............ 4 Test Pit,No. 1..44.0.._mmutes per inch Depth of Test Pit____________________ epth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------ -- ------------------------ ••-------•-•--------- • -------------------------------•-........ - o Description of Soil _�C. .. `¢'"• ._.:`�` ' ®l�I --------� f E + ►'- 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 T?TI.;. 5 of the State Sanitary Code—The undersigned-furtLar agrees not to place the.system in operation until a Certificate of Compliance has bee sued "t e boar 1 p Signed / ? •---- ---•--.---• -------------••......------•-----•---- •-----------Da._......-------• Application Approved BY•---•... --------------------------••----•--•----•-----------------•-•...._......._ .,/'r� ..' Date Application Disapproved for th following reasons:................................................................................................................ ..............................................-•-•-------------..__.._......------------•-•-----••--------....._....--•----•-•-•-•-------•---------••-•---•---•-•--•----------••...-•-•--•---•...._.... Date PermitNo......7 ...................................... Issued....................................................... Date THE,-COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,< c7 -��: C�rr#ifir�tt#r of �unt�ltaanrr THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed { or Repaired ( ) by ! X --------- Installer has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIOtj SATISFACTORY. 7 DATE.......... ... .-_ it................ 1:.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ^" ...................................OF.............................................................•....................... No. `�� FEE..................•..... Disposal Works Talaaiutraiun rrntit Permission is hereby granted__x.__.. `ek«_._........ �.1' !�' _ _ _ ._._ _ to Construct ) or Repair ( ) an Individual Se,rage ispos y em 31 Street as shown on,the application for'Disposal Works Construction Permit No. .____11_F......... Dated.'_ "".� .................n..... 1 __. . ................................... Board of Health DATE.. �— FORM 1255 Hoees''&' WARREN, INC.,rPUBLISHERS EO CAT IO SEWAGE PERMIT NO.� VILLAGE65 INSTA LLEfR'S NAME �& ADDRESS B UI-LDE R OR OWNER DA T E PERMIT ISSUED DATE . CO--MP.LIA.NCE ISSUED -;2 ���� fe k . m e X R st x Nz�tl"e !f 'ice• �"���y��yy,,'�' 't n 'r��t •} � t ,. -t. { ,•.t+ ,�,.I' �'"a�y [,�«kT � 11 3 ij 44 C te�'W'a� f4 P F 'A ¢ r r * $ J' f/ '1' '•� •, ��,,sVs` ¢ v 'fit" r vr(,'},�' + t Z2 ry. r.. ., ,N• a M;. r'{'kt sx i� � a t .� t fi �'�� re y � � � r a.,r 4s Y;� plat,; •fn 1x-1 9{i �{��r.. iR's,q sa�,Y� �.v � a', �, +�• 'A ,` rFt�. ., rCO� x:.. �' /./��' .�j1 4,t .Y r I' 'j ', I 5 \ � ' 'V} .. , ! Y•N .' �. 1j' M + r`x 'A r�`tY k a y t +5 v a V + yy t t.r :[ i p •-.� .1.. 'O� �� A. .. ";y g5>Aft t +t sk 'tC }"" ~''� , ! t..'�r�$t '* 1•.N n¢ t i a} K r at n i t .. 7 ast I * a. J M '�,• pia i �,f rt Y +r /�� f t • �O Sf tI_Y +r ty� nra e yy' ��•,�t KYr #r-trq.. M r.rY .-J �9i-r.,' r .. �, 4 I q!t it a..., a•4Cn a., � ' t tki. '�a 4r K S. � c t�'r� I��t �'�' at�x ;ed�. • � t, ' n:rv� s-ra�' � 1ra.; 4 Ni ®` OF JM \... '� 4 P L. s+•.� "r � _i_ _ ��t� �a„5• 4 ; `� '� j' q I > x 's4► 4. p 1� Y4, ry� � � " k k Mgr `'' `V O� _ d. ROBERT,,,. tiG. ' ,.,' ` �� r Y4,l at �qa�..a<3 1 v k>^ r "xF+ri•° ��\ '/� P. U BUNIKIS '" ;•H ''Y a ca sot J ! '1Y pNo 22162�o 'Q GISTS + r3.t�t r is ! �y s��i,., r,R .a'2 .r.. O,(y. �C�\ t ;4 'F3 ,u.,.,,•r Al 4NAL of t � r t .Rf�•-^'t' v t 1 Yt'•• �, �.!\E� 1 t y@' •r �!+ �"Se � ;� r.t S t 4 ; t .LEGEND 't ?ivE �` gF ,oxS`fM't` 3.R:OT ELEVATION. "Ox0 I �'�, CERTIFIED PLOT Pl~'AN t, :4 E •S.T� ;;C 0 N TO U R - —' 0 '- I ,,* O �, L E V A T41 O N L 'T— 1 ?t12�� �o�✓ s *01 , S k1 t7 - T E ,• F I D.',PONTOUR O . _._._ .�. ..Q 1�ED -"BOARD OF HEALTH 'j G`!•,�a71' Isljol. t p: 'AGENT' SCALE / "40 DATE r ., ` GE NGINEERING CO. ING� - CLIENT .GE3�L I CERTIFY THAT T.HE PROP40SED ^" G1*;lIt, REGISTE,�tE01 JOB N0.77o08--- BUILDING SHOWN . ON THIS P�.LAN,-� s kx° \ �Kal. LAND. CONFORMS; TO THE ZONING ..,LAWS INFER ,, „ SURVEYOR OF BARNSTA LE ,' MASS ST, r T2 MAIN ;>T CH. BY i&A 4'S0 IV�O��T MASS HYANNI MASS. SHEET-- -'OVF� 2- %1 r.,eta t 4'q>„ ti t ` s - i - N'sk<. _-_-__ DATE REG. C.AND SURVEYOR ell oil z. # w-`*$ .c+. -,,5. . .- - •: Fy.- may)._ ;/ +n -k _ 1 �• .. ..�. � ,_ s. - _ :m -' ..'r� •. ��:�//I7-6+�1 T;�{�J.���/-�i TiQYt//'� �1� G _ Y Rom. i�Y® /TA � �e�ey'`H'���/..-/ �+ E/l.�O lei/ aw 1_ }ram -.®VF..�'�:I�i .�. .._• ` -z, '' _�5 -�-'u f"'y. 4%Ec.. „y;,< Y.`� +iF� �,!'t. a�A�L/_�/'M W/ L414 G �� E 'OPJfa ' G - <� cerr P t� .a s7-ieosy ®row::s� .q L L:,�� usFn 7 z �!'*:liak�.nf- - MIN. J��"�T_�Y/y� { 1. /y� �l W/V��Y�y G od COiiE� CLEAM .SA/VO _ m� ;• BAC/fF/LL _ L/QUID LEVEL 4"CASE • � a`LAYFR /ICON P/PE � �O 0 U o a o ���J°o I � -� r - :gib M//V.P/TCN GAL. • y a m o AF /9 - /B PoJt P7 D/ST< o 4 WA SHFD S7?�NE SEPTIC TAAIK . r, o • . • • e • . . o. e a 4 i F x BOX o • • � • a e • • . ,®e e . �� .- - � a vD � 1 . eEFFECT/VE � e . •v 3�4"- � �2 . . ° � • ° pEPTN • m e ` ° o J•VASHED STOiYE ' •�°:a'�- � � 4 � • ee ® . • • ► 1 Doc . • o vs a � • • • o o • • . � p cb� PREG45TSEEPAGE lNVGR•T ELE11A774ONs fr - . . • ® . . . a pa o O/7 OR EQU/V. /MVERT AT BUILDING 69•O FT, 6 FT PMM. //4/LEa' SEPTIC T.4/V/C 68,S FT /O FT. O/AM. C`CSEE`T l/LATION� OUTLET SEPTIC 7-A/VH G8.3 FTC INLET D/ST/��BUT/ON EOX �8 F GROUND WATER Ti4®LE O(/TLETD/STR/BUT/ON BOX 6 9 FT _ SECT/ON OF INLET LEACHING .O/T . 67,s FT SEyVV.4CE ®/S�OSA L SY.ST�M 7:A&lJL.�TIDN L EACHII V orw �/T o/MEMs/o N �1 3 FT. DES'/GN CR/TER/A sfr.a L E : %� " _. /= o" NUMBER OF EEDRopMS 3 D/HENS/aN- C FT. /N . Gi+RBA�E o/sPosAL uw/r SDI L. LOG IL ?SST TOTAL ES'TI/r1ATE0 FLOH/ 3 3 D G.4L.1®.oY °-SOIL TEST , `/ SOIL TEST#2 ' ` ` /�(UMBE/P OF LF,vcJIING PITS=. FCEK G4:� ! ELEY, ;GATE aF SO/,� TEST 7 SIDE LEACHING PEAt P/T 6oTTo/+w LEygCH/NG PLR P/T 7 �. Y Y RESULTS H//T/VESSED Sr. S4• PT. D- Z pER CGLAT/Old MATO�/ Z 2 MI M�//I KC/�f TOTAL LEACH/NG AREA 2'��S FT. AGsRCOLATloA/RA7' •1*2 MlN. INCH RESERVELZA REA 4 FT. s�eso c.. h _ S4� ZN OF M v i Z _ Ass �. SA i✓�` n - O�� ,RoBERTO'7 3. T/fR 6,� yc w/O S G I x „ - BUNIKIS- °' f Sj No:2216Z p 3 ,,_ '� �- �(r tvQ �c - •> �-� _ x-, � .< � to O S� •�� _ °"�'s..; a�" : F 3 K F+.:..<'� '> q �'S. aS . fin A >!` ..'�..3 . 8K- "-:-�:+^ : ._.n"k•+,.. - -....._ .. :_s`^.ham+ �',. W4. .. -:, r.� ,:,. ,E. ,..;:..r...¢..s d6:�h..w•.w_,„_�.s.s.-.�.s:•.:-x4... ?k-r• �..;f�:.,..:5+.'..-4>r.vY.�'.+.°^i<°=,G"".=`:w_d.;•. >`!.c�":�.,..s:p.4..,P.a..`.-�w"a,�.q7;y 7ps-.r�„,.,�:..-....•._ter•.<r•....:,-<:•,-Lg"._v,.- .r....x.f.".-zs..�,}..E-:_.'''�r �a.t'-': ."_•`��'+5-yr`r.X7 .`,...'�..,.rP!.t,..y'�'�.$^� 'Y�:e',�,,,s�._.'t+'`,b• 'kM' "w.�<, R e .' ` +.� ��33,��i.p<y.•-a k.t'� .`. .-�,@'%k.-��'-.P.'".^.=� ti,�..�"'".i�-":;�`'r 8•�.:'r, t''�#.;=..f';. `.. n2>:-'.. - �c.,�,•_.. _ .n'k..__".`<.�^•-`-'�" ... c... ..3:,: