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HomeMy WebLinkAbout0094 VALLEY BROOK ROAD - Health 94 Valley Brook Road, Centerville LA= llll � UPC 12543 Now 53LOR HASTINGS. MN ` / ( JU 2tm1� � oZ.�� TOWN OF BARNSTABLE LOCATION SEWAGE# O VILLAGE CAkUJ 6/'J1 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. u i l �j FK�,�1,(�IRC!h, -11`f cal'aZ 9 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS �f1x OWNER PERMIT DATE: 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 leachiniz taci,itvj. Feet FURNISHED BY ~r 0 Al gl �3` Uc � ` e I� No. ""Z( � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplifation for Voposal *pstrm Construftion 3pCrmit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. V(/� "'l e I� �� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel i 6 &L&VA ,0 Installer's Name,Address,and Tel.No. �^., Designer's Name,Address,and Tel.No. 1(li1'Ea ym a Type of Building: -114 C2141 Z d®q� Dwelling No.of Bedrooms WA— Lot Size sq.8. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision ate Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Titllofe nvironme 1 C e and not to place the system in operation until a CertificateCompliance has been issued by this Blth. Signed Date Application Approved by Date Ll 2. Application Disapproved by Date for the following reasons Permit No. 2,0/l —l 1 Date Issued Z� j No. � ' ;. Fee ­7 S' THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: 4-- Yes Y M PUBLIC HEALTH DIVISION - TOWN.OF BARNSTABLE, MASSACHUSETTS ftplication for Dispatal 6pstem Constru tion Permit ►� Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components ,Location Address or Lot No. I!? ""A Owner's Namte,,,Address,and Tell.No. Assessor's Map/Parcel d`+V Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: ''� ? '� a9 q;lWA- Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers(`-)'Cafeteria( Other Fixtures / Design Flow(mina required) I 1 gpd Design flow provided /V/ gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Y Description of Soil Nature of Repairs or Alterations(Answer w en applicable) oury Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 oP ironme tal Code and not to place the system in operation until a Certificate o Compliance has been issued by this Board . Signed DateA lication A roved b 6PP PP Y --•�� Date e0l Application Disapproved by — Date r for the following reasons Permit No. Z t -^' s Date Issued L � P THE COMMONWEALTH OF MASSACHUSETTS V4 BARNSTABLE,MASSACHUSETTS �•� Certificate of Compliance t _ THIS IS TO CER' I>Y that the On-site Sewage Disposalstem Constructed( ) Repaired( ) Upgraded( ) Abando ed( )by 1( 1 at V has been constructed in accordance. 1 v T with the provisions of Title � and the for Disposal System Construction Permit No.? •J3�dated `7 I Installer Designer #bedrooms W`/fit- Approved design flow N , gpd The issuance of this permit shall not be construed as a guarantee that the system w will ctio?as deli ;.ecdl. --- Date Ins gctor r; No. Fee �r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS VBpDsaY 6psterrt Construction Verrnit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at A ,A �i r1 1A)h VA and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constr u cti17,1111 on must be completed within three years of the date of this permit.42 Date "� ( 7,1 1 1 j Approved by tit c� Commonwealth of Massachusetts tg9- I�1 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Valley Brook Rd. V Property Address Shana Miller Owner Owner's Name information is required for every Centerville I✓ MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 5 i i531 S' on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Jim The Inspector Man use the return Company Name key. P.O.Box 784 ,Q Company Address West Yarmouth MA 02673 City/Town State Zip Code 508-364-4398 SI 14430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes ,IH OF,jygS,s��G,'. 2. ® Conditionally Passes MICHAEL N 3. ❑ Needs Further Evaluation b the Local Approving Authority o SEARS y pp g y * No.SI14430 co Z 4. ❑ Fails %;T°FR ��°;oe.mac �N SP 1111 4-12-21 Inspector's Signal a Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: e D Box walls are gone and needs to be replaced 2) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 AN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Valley Brook Rd. u� Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts r� ,p Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2019-66000 gal 2020-46000 gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 2019 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form . �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. !% 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 6-4-82 #82-323 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form �- w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 22"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1600 gal Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? ' Tape-Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with baffle in and tee out, both covers at 22" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �. ,p Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form tiI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): q Depth of liquid level above outlet invert 0 p Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 1 outlet pipe, box is 32" below grade, walls are gone and needs to be replaced t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I i c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Valley Brook Rd. u Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I Commonwealth of Massachusetts ,lip Title 5 Official Inspection Form iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 1000 gal pit, pit has clean walls and wet bottom with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..........«!% 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 — i Commonwealth of Massachusetts Title 5 Official Inspection Form fi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 94 Valley Brook Rd. ----- Property Address Shana Miller Owner Owner's Name information is Centerville MA_ 02632 4-12-21 required for every --.. _..-.. ._. ---- ----.._ .. ._. .. .. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately BackJT F 0 0 Y 9�pe 376 D � Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 16 of 18 t5insp.doc•rev.7/26/2018 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �_ �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd. V Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 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: 6-24-82Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts �v p Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 94 Valley Brook Rd. Property Address Shana Miller Owner Owner's Name information is required for every Centerville MA 02632 4-12-21 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included ---� i a NlJ �ObL h > t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Town of Barnstable M B' � Inspectional Services Department P'F639,`lk Public Health Division 200 Main Street, Hyannis MA 02601 l humas A McKean,CI IO Otl-ice 508-862-4644 FAX 508-790-6304 Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 C MR An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE ] YEAR DEADLINE CRITERIA distribution box is above the outlet invert due to an ❑ Static liquid level in the d overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool; or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well pply❑ A portion of the cesspool is located within 50 feet oeal private asses f the wateer analysis with no acceptable water quality analysis. (This ) P indicates the well is free front pollution). TWO 2 YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to 1-1-10 components; etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) O ER Repair deadline:_ � ---------- ------ O:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc I Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r :a ��_„_•T,;;;�' 94 Valley Brook Rd Property Address ,tea Jacqueline Renick s;w Owner Owner's Name information is X, required for every Centerville MA 02632 8-1-18 5««. page. City/Town State Zip Code Date of Inspection ' 110 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 ❑ Fails ❑ Needs Furth uation by the Local Approving Authority 8-1-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection ,Form i� ws i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 841-18 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Co nditionalPass" 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts Title-5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville 01 MA 02632 8-1-18 page. City/Town 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 El ❑ 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 ON ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form w. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valle`�� :,_•T, :> y Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C�_n T•�I 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town 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 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd Property Address Jacqueline Renick - Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town 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? ® ❑ Wasthe 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 flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts r� Title 5 Official Inspection Form wa cil Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 Z No Last date of occupancy: UnknownDate 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts .� ,p. Title 5 Official Inspection Form I.-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd .21 Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 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: N/A 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form HI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 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: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 12" Sludge depth: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts 3 Title 5 Official Inspection Form <;�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd J Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts ; Title 5 Official Inspection Form w YCC'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town 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 ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 - 1 Commonwealth of Massachusetts Title 5 Official Inspection Form �,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town 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.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* I 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts + Title 5 Official Inspection Form w' I�i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 94 Valley Brook Rd 1._J Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ 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.): Leach pit in good condition and empty at inspection with stain line at 24" below inlet invert. 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.cloc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form r�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately AL V. 4 0 J". r , 'OF t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts r� y Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 page. City/Town 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: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained.from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I .a c Commonwealth of Massachusetts ,w Title 5 Official Inspection Form ! i,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :. ` 94 Valley Brook Rd Property Address Jacqueline Renick Owner Owner's Name information is required for every Centerville MA 02632 8-1-18 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 CA-ao (yj Commonwealth of Massachusetts j 1�/ Executive of Environmental Affairs DEP X 0 fly t Cr 1 Department of 1996 Environmental Protection i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -� PART A 9 CERTIFICATION Property Address: `�y U�1�.��co� C -'�;►'���'�r �'l'a , 0? '3� Address of Owner: Mz (if different) Date of Inspection: 0,\; 6 Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o B ox 2384 - M ashpee M a 02649. Tel: (508) 4771420 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s Signa r Date: �P 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer,if applicable and the approving authority. • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5y �oW t) Owners : r.�c1L Date of Inspection: �1 INSPECTION SUMMARY: Check A,B, C,or D A)SYSTEM PASSES: XI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 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 determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated",explain why not. ---- The septic tank is metal, cracked, structurally 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. ---- 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 ----- 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): ----- broken pipe(s)are replaced j ----- obstruction is removed C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : gy Owner : Date of Inspection : C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 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 SAFETYAND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING 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 analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. 3 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4y Owner: Date of Inspection : C\`\(A�� D)SYS T E M FAI LS (continued) -- 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 over- loaded 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 NO T 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 cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. h SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: cl ck Owner: ,��� Date of Inspection: 11 1l C E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 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 compli- ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property ddress: Owner: k&vc.,oc_ Date of Inspection: Check if the following have been done : - -x Pumping information was requested of the owner ,occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components,excluding the Soil Absorption System,have been located on the site. -•-x The septic tank manholes were uncovered,opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions,depth of liquid, depth of sludge,depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods --x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: RESIDENTIAL: Design flow : _S30 gallons Number of bedrooms : o'er Number of current residents: e-Z— Garbage grinder (yes or no) :N_-)o Laundry connected to system (yes or no): � Seasonal use (yes or no) : r� Water meter readings,if available: Last date of occupancy : COMMERCIALIINDUSTRIAL : Type of establishment: Design flow: gallons/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 sour a of information: System pumped as part of inspection (yes or no) : � ......... I yes, volume pomped: .................... gallons Reasonfor pumping :............................................................................................................. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: u � Qsxi'C Owner: Date of inspection: 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) --- Other (explain)........................................................................................... APPROXIMATE AGE of all components, date installed (if known)and source of information Vk.... ....... ..kl.M.S 'Rr . ................................................................................ ................................................................................................................................................. ................................ Sewage odors detected when arriving at the site : (yes or no)....... -� SEPTIC TANK : ... (locate on site plan) Depth below grade: ...lZr.. Material of construction: ...1 concrete ......... metal ........ FRP ........ other (explain) .... ......................................................................................................................................... Dime... nsions: �x�x.S. Sludge depth:....0.`..... Distance from top of sludge to bottom of outlet tee or baffle:.......... ............. Scum thickness :...0>.`.'.......... Distance from to of scum to top of outlet tee or baffle J..Q.....` .......... Distance from bottom of scum to bottom of outlet tee or baffle:.....J..fa.............. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in rel ti n to outlet invert,str tural integrity,evidence leakage,etc. . ... j ............ i ..►..... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `l Owner: Date of inspection: 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 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.).,...................... ................................................................................................................................................ TIGHT OR HOLDING TANKS:.. Z.N..Ct (locate on site plan) Depth 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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: c*%4, v W�� Owner.'�c_tL Date of inspection: Cikk\. DISTRIBUTION BOX-0 (locate on site plan) Depth of liquid level above outlet invert:... s1 Comment: (note if level and di ribution equal eviden f soliI!, rryover,evidence of leakage into or out of box,etc. ...`��...�sa.. .. �.�►.C7 PUMPCHAMBER:...O��. (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):.... .. (locate on site plan, if possible; excavation not required,but may be approximated by non- intrusive methods) if not determined to be present, explain: . ................................................................................................................................................ ... .... 1..t. .....��. ...................................................................... Type. leachin gPiks,number: .... \ Q leaching chambers,number:........ leaching galleries,number:........... leaching trenches,number ,length:..................... leaching fields,number,dimensions:................... overflow cesspool, number:.......... Comments: (note ondition of soil, signs of hydra failure, level of ponding, condition of vegetation, etc.) .. . .. .�\. ..... ..... �.. .... .. J Ir _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 'k y Qaut::�,6ec'c Owner' Date of inspection: CESSPOOLS:....NQ. (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 ..................... Indicator of ground water: .................... 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 the site) Material of construction: ................................... Dimensions': ...................... Depth of solids: ................ Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.). i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : kk vc�-�- � � Owner. Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' I A Z �Lo s v az- `I DEPTH TO GROUNDWATER: Depth to groundwater: .zSfeet Method of determination _approximative: U,.S.:.�e�o1.acot .. a� +��. ..... ................................................................... ................................................................................................................................................ ac. � 4/8/2021 ShowAsbuilt(1700x2800) fie LOCATION SEWAGE PERMIT NO. :LET A- Az /2,E -2-7 VILLAGE INSTALLER'S NAME & ADDRESS SUILDER OR OWNER DATE PERMIT ISSUED X I 0 DATE COMPLIANCE ISSUED j �S \ ;y� 1 ti.3 https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=189161&sq=1 1/1 SEWAGE#' yII,LAt�fi - •— eut r U r �e ' ASSESSt}R'S`I�r#AY&LOT. Ms.TALLEI2 .I�tAI c� SORE N S81'TIC T,43�IK CAFACTCX I,$AC1iF1`tG F NO.OFBfi13i�40I�S; �; EUILER 4R t3WIER pERA 'FDATE ©wL.flati+ICEgA" ' Sepon Drtau►ce BecwesnFhe Fect m#jj#Wgj.uUS;tW Groundwater Table to the Batiom of Lsacl tng Facility Pnvate Watar Supply; ell andDipc ng Fac lccY E soy�retls exis€ Feet on-:sits cr wit8un.?AO feet of Ieaclnng far.�ty) Edge of Wetland andI,eaching Faal3ty(TfY wetlands exist I"eet Z A 1� D C o p Ut V �A-F- �391 �- ss f ru No...........all::3 THE COMMONWEALTH OF MASSACHUSETTS BOAR® F` HE T f .... ...OF......................................- ........................ t Applira#ion for Uisvniial Works Toutitrurtioll ramit nv Application is hereby made for a Permit to Construct ( or Repair ( ) an dividual Sewage Disposal System at: It .. .. -_____-___--•••......__- -----•----•--- ---------_--_._-_ �J.... (��MJ .. dres'!�•' 1�J ���r�V �'�L�/7�y ......................_.._...............---... .. -..Y._`.'_.••'--,----________-•--------__ ____-------••------•------._....f...... ..._..---.............---..........._..._.._....-- wn r ss aW .............../l � Y � .__....... ------._....1�.._ ... ............................................................... Installer Address QType of Building Size Lot....Al._�'��.....Sq. feet U Dwelling—No. of Bedrooms__._________ ( g (/cam,.., ________________________Expansion Attic ! Garbage Grinder pa•, Other—Type of Building •- .................... No. of persons......G_................. Showers ( ) — Cafeteria ( ) a' Other fixtures ____________________________ d -------------- ----------•- •••---- W Design Flow_.______._._......................gallons per person per day. Total daily flow..__._._3 _.________._____.......gallons. WSeptic Tank—Liquid capacity .gallons Length..... Width_........... Diameter________________ Depth................ x Disposal Trench—No_____________________ Widt _________________ Total Length......__.._.___.___ Total leaching area....................sq. ft. Seepage Pit No........,�--------- Diameter_____ __________ Depth below inlet..... __._...... Total leaching area...30_2_sq. ft. Z Other Distribution box ( ) Dosin ank ) M ~' Percolation Test Results Performed --__ t V __________________________________Ie- Date.___. ' _ _._...._-. aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r3, Test Pit No. 2..._............minutes per inch Depth of Test Pit.................... Depth to ground water........................ rp J....... a ...... ....................... Description of Soil........-Q-'n- O -- ............................................t-� S'-aic.,cJC ----------- / -�--------- ------- -------"�L-----J ------------------------------- x -•--•-------- PP c -----••-•-----------------------------------------------------------------•---•-•----•------.....--•-•--- U W -•-•-•------•-----------•..............•------•-----•--••----•--•--•-•--•--•------••--•---•-----••-----•----__.------.._._.._.__...---•--...-•-----------------•--•-•-•-•---------------•--------•------ UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL% 5 of the State Sanitary Code— The dersi ed further agrees not to place/thheeeystem in operation until a Certificate of Compliance has be is ed by bo of health. r�Signed_ � d'.---•----•.................................•••------..._••-------------•- -------- -----......._ / Dt Application Approved By...................... - /l%�l * ,�7 ---•------------...._.... ------�.-�. �-'--....._.. Date Application Disapproved for the following reasons---------------••----•-------------•--•--••--------------------------------------------•--------•-•••-••---•-- ------•---•................•-----.._._..--•--•--------•-------•--•-------•••-••---•-----------------....-------•-••-•-_..-•------•••---------------------------•--•-----•---••----------•-•-•----------- Date PermitNo................................. Issued....................................................... Date No................ --!-. .............. THE COMMONWEALTH OF MASSACHUSETTS l . BOARD I O�I - 1.................................OF.................... Yam, , pphration for Dhipaaaal ork,s<) or Tom4rurtinn ami# Application i hereby made fo Permit to Construct (°� Repa' ( ) a ndividual Sewage Disposal System at: // ll d.3 V ; ....._.__..y..�.- ....._ ...... .. ---•-----.......� ...... . V D cat r'is"S / / No. �I� ------------- - - •-- ..�•"......-- ....................... .........`..... ---••-•-•- ------•--•/-'-•-7 ...... Vd a .. A= ....---_-•{ Ad es.s.---. y ----------------- .: b � Ins?aller � + � Address Type of Building Size Lot..............................Sq feet U g Dwellin ,. No. of-Bedrooms .._....._...Ex ansi Attic� �— -- �-�------------ , � p an (��';dj : Garbage Grinder (� 04 Other`-'Type of Buildin91_ ------------------ No. of persons............................ Showers ( ) — Cafeteria ( ) Other . tures •----•-----•--- •-•----•---•----------------•-•-•---.--••----•-•--•---•--------------- ---.......- j�'� W Design Flow........... ......................gallons per person r day. Total aily flow.___...3 _:_.....' .._..........gallons. R; Septic Tank—Liquid capacit+ ..gallons Length................ Width.!*........... Diameter.-.-.-_--__---_- Depth................ ^Yak x Disposal Trench—N ......Wid .:................ Total Length_._.. ......`.`:_. Total leaching area.... sq?'ft. Seepage Pit No......................_.__.. Diameter....J ...__..... Depth below inlet_.............. Total leaching area.�` �.......sq. ft. Z Other Distribution box ( ) Dosin W 49 Percolation Test Results Performed by ---- Test Pit No. 1................mmutes per inch Depth of Test Pit.......:_.......... Depth to ground water......................... 4A Test Pit No. 2................minutes per;inch Depth of Test Pit..................... Depth to ground water........................ t / O Description.Qf.Soij — � -- - 4 ► G' .� !V V -•-•---•----....... ` ...................•----------•------------•------------------ •--•-------•-••----•-•-•••. W _________________________________________________________4---__---____•_____--•-.--------__----.-•_----------_-____.___.-.-___-----__.____.........._.__._.........._............._......_......_..... U Nature of Repairs or Alterations'-Answer when applicable...... ......:................................................................................. r .................................................... i Agreement The undersigned agrees to install the aforedescribed Ind' ideal Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Cod Th der - ned further agrees not to place th syste in operation until a Certificate of Compliance Chas ben ' ved b e b rd of health. S* e , - �j ........... ApplicationApproved BY....................................................... .._...------------------ •-----••---••. ......-----••--------- Date 'Application Disapproved for the following reasons:--•-----•-••----•--•-----•-•---••--•-----••---------------•--------------•------•-------•--••-•-•-•••.........-- ....................................................................................................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date r 1. THE COMMONWEALTH OF MASSACHUSETTS fi BOAR r�OF4AM 1 - ..........................................OF..................................................................................... frrlifiralp of Taautplitattrr �,,-- .THIS IS TO CERTI 'A�he lg4,vage Disposal S stem constructed ( ) or Repaired ( ) by...........6. ler �1 at.................-•1.................. •---• ....................................... has been installed in accordance with the provisions of TI WV )Xf Z3e State Sanitary Code as,described in the application for Disposal Works Construciion Permit No......................................... dated.................................................. THE ISSUANCE,.OE THAS CERTIFICAITE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL,FUNCTION SATISFACTORY. DATE..... .?f.�r ._... Inspector__..__.. p " A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LTJ�1 - ` t 7.r_.. ..............OF..../ ...�... as No......................... Permissio h atair granted-------••-•.............••-•••••-••--•--•-------•--------=...... /'� ----------- ............. ------.........------------- to Constru orr > Sew, is osal e st fr, atNo.............•---......-----......--•--------•----------...........------•-••-------•---........----•-•----......•-•--•-•-•-...--•-••...... ".... as shown on the application for Disposal Works Con tructi 4 it` _.....__ __ ed ....................................... ---------------------------------------•• •• '".................................................. D ....................... Board of Health ----------DATE------------------------------------- ---- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �St►� GLc- FAM1�`C - � BEORooM a ND GA�ZHAGE �j2tNDE2 40 DA►l,Y FL0W 5EPTtG TANK = 33Ox15C>% = -4956.P. P u5E I000 GAL. >G 015P405AL PIT Q,5 to 00 6At_, 150 i S►fltTN�At.L A21=D. = i rjd S,G '. � _ . - -- 50TToM AQ-EA= 50 5,F• P'r i fix? �3 8 : -ToTAt- C>E1516N = ArZ5 rW. vTAt_ pA i L-{ FLO►/� = 3 O �.P� `� o I I I -r 3 � PE.2coLAT1o�1 2ATE 1''Inl 2MIN OW-L~55 . • -- _- - - i- D °�s�� �' 11 It qA Zg t6,i y, c t loll►_/ 5tlC;tIAf1Q at.°•N \._t'S 36; SAXTitR `lrifl /�� f I . .. +'`• `met � IAI TOP FND= 140 NOLE LoAW Loa t3o�C INV. Ssc,�c 3S'� I�� Z f UUU INS 3S•L TANK- GAt,. f GoAfn3 PIT ..._ . ...---- . ._ ...-_,- • �� wlTu �S•Z 3S•4 WAsurD V + STONE _C1=2.T1F1GO PLoZ PROFILI= L064-T IOW S AA ' 25 No 5 CA,Lr-- 5CALa Its 6-7-3-SZ uo �Qt. PaopoS��U I SNowN p t-A zErI I GC-: Nt=a.Eo r-t GoMPLYS vJ1-rla-T Iar �l S�BLIt�1� � �� /a1.1D Spot : GK S�_�Ru►tZ1✓M�tit r5 OF °� T�vJ►�I O>= BAR;V�L3w� ,v,N'D t�', {�0'(- ( _ DAT LOC_P� CD WITF111J T C DD LAIN ► (1a� I` 1 3 EL""'��� - I� t � • " 6AxTEiZ.t'_ IJ`(E INS. ' I i REG i S"t<=2E•-D't.Aw o 5 u ZY E�(o2S -T►AtS PL/•\Kl 15 NO-T >ki AN o57E2VILLE - ti1A55. SV�'VG-`( '1 >1E 4FFjE"t5 StlOul� N��T tom;^ V�f=-(DTb pF_TF-.S2-M1�IF: t_��� 1._tNF�j /11�Pl..IGP�►�-tT' =;N-Gt< ��c x-��.i�`� -- LOCATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS . i UtL DE R OR OWNER DATE PERMIT ISSUED 0�efox L7 �9L OAT E COMPLIAN-CE ISSUED � 4, AC 4c 3Y 3�