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0046 VICTORIA STREET - Health
46 Victoria Street Centerville P 148 064 - E a a Omrford, NO. 1521/3 ORA 10% { 1 TOWN OF BARNSTABLE LOCATION L4(0 V l(nzz� Pt S'1 SEWAGE# 9®`Q- 370 VILLAGE G1Et,9TC7LY(LA- ASSESSOR'S MAPP&&PARCEL 8 INSTALLER'S NAME&PHONE NO. dAR W tmgax e auq-cr0 SEPTIC TANK CAPACITY L 1426,p C.t)d.lS LEACHING FACILITY.(type)`l-d r4 d,4A,48M$ (size) a.' 3 t X -;�.5 r NO.OF BEDROOMS 3 OWNER CA669, MC-N` HARJ PERMIT DATE: (® ^ l" ;ko COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 1 A Feet Private Water Supply Welland Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) NIA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within /� 300 feet of leaching facility) A Feet FURNISHED BY CAMUX06 102 G�-T �Q 2- 32 i 44- Z9.4, B-► t. � o c Vol 5 3 `o z R-? $ I o VO4T 0 Lk -5= 30.1` ; -o No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Bispo8al *pstrm Construction 3pPrmit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4(p V un ( ST, Owner's Name,_Address,and Tel.No. C-AY901k GNr11A11-1 Assessor's Map/Parcel 1+9 A, Ta ,? 3 R AC LU. MW Installer's Name ddress,and Tel.No. SO 71—g la 7 j Designer's Name,Address,and Tel.No. Ce�Pet✓to( ao - 6 000L� , �"� Cam, oe�Rgt vc, T_MC US3cep c - CR�t�' Ef 6. (-t/; G Type of Building:Dwelling No.of Bedrooms -3 Lot Size i S,40`G/ -- sq.ft. Garbage Grinder( ) Other Type of Building �(1)6MAA _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3NO gpd Design flow provided gpd Plan Date 9 —30 ).A)(9 Number of sheets f Revision Date Title_ 46 V 4 .16 PL(A STROP r G&Nf77&W((i(1v Size of Septic Tank l nc) d—&#(-CL005 Type of S.A./ .�S.I jUp <54< } Description of Soil�l1E° (�,pa¢2�� �S�N 7�� i 7 PG Nature of Repairs or Alterations(Answer when applicable) U!Se I ®O _ vL& � �c,I.CJ -act D L��� 'TU /W Soo J H-�0 uzw �c� �s J 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 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Si d Date 1 0 — ( -;Lot? Application Approved by Date (0 Application Disapproved by Date for the following reasons Permit No. Date.Issued No. 2,0(� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppl Lation for Mispo$al 6pstem Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. T(a V la- 1A 9C•, _ Owner's Name,Address,and Tel.No. k Assessor'sMap/Parcel t-�. (A4n . G YB®�' F.AIIY A Installer's Name,Address,and Tel.No. !;a _- f'j'7 Designer's N^j ame,Address,and Tel.No. d*PEwtoe/Ao r- ©cJq, du , - N�V41-jG. ZNG C�SGu Er W C Type of Building: Dwelling No.of Bedrooms Lot Size 40 42 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow(min.required) gpd Design flow provided ,( 1 gpd Plan Date_T' oo' j ,A�Number of sheets Revision Date Title VrdTr Size of Septic Tank ,U toe) G-e _U Type of S.A.S. 6 � rc Description of Soil H1�►) � � + �p «� 1q014 PLOW Nature of Repairs or Alterations(Answer when applicable) IJ<1- 1 r»0a` ^/56;T6G� {-/d�7�r1 ,�� V -A 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 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date I 0 - t -1(1(q Application Approved by "'4�^ Date (p I -I U1 1 Application Disapproved by 1 Date for the following reasons Permit No. Eg®(zj � Date Issued 16- f-1 !J --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired ) Upgraded( ) Abandoned( )by CAPew 1 D Ak6fsk-mm-Z—AL On6` at 4(a 11(C"MA..t AST" has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.?O(cl- 3 7 O dated (0-1 Installer I t n / Qlx!, Designer #.bedrooms Approved design flow gpd The issuance of this permi shall not be construed as a guarantee that the system will function as de ' - ed. Date o h-T Inspector a ______________________________________________________________________________________ No. p`U ( ' / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30isposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at A � 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:Construction must be completed within three years of the date of this permit. Date 0 ' l q Approved by / If No, 3500 P. Town of Barnstable Repdatory Services ii a+twsreeM IRichard V, Scali,Interim Director 1659. Public Health Division �6p"o"rp Thomas MWean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax; 508-790.6304 Installer c�Designer Certifiieation Farttt - Date: �- �"I Sewage permit# ?-019 -1-7 0 y� Assessor,s lV1(ap\parcel Designer: 3C C,n tJ1ee�(nc C,, Installer: Ca cw�cl�. Evil er cis Address: 2$r`r` Crnr,b.erc iii H wa V Address; ► 3 Cc nn,m ucf a 1 c.ij Ecisk WafeAkoYl Nq 62538 On t O i 2Utoi C4P,wiclevrPrfse�S (date) was issued a permit to install a (installer) -_ septic system at 1 V CC,6 rya Akre C,4_ based on a design drawn by (address) SG E� lnr.�cCh �1C,_ dated 5gity w $61209. (designer V I certify that the septic system referenced above was installed accordifi to the design, which may include minor approved chang s such as substantiallylateral relocation ation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils Were found satisfactory. I certify that the septic system referenced above was installed with major changes'(i,e.'cr greater than 10, lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& 'Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was construe of the 11A approval letters (if applicable) ce with the terms 0 JOHN L �Gm CNUR ILL Jp. G stalle];4 Sigmtur V(L A N .41 a 1 signer's Signa -fix igne s St mp Tlere) PL ASE RETU TO BARNSTABLE OF PUBLIC HEA H D S N. CERTIFICATE COMPLIANCE WILL, NOT BE ISSUED UNTIL 13OT IS FORM AND ,AS_ TIiAJ&YOU C BULT CA_R1) ARE RECEIVED BY THE BARNgTAgLE P HEALTH DIVISION Q:18ent1r'008l9ner Cer IfIcAtlon]Form Rev 8-14-13,doc e TOWN OF BARNSTABLE LOi,t.1lON � C'koC, S-t- SEWAGE # VA'iLAGE �y 1L�- ASSESSOR'S MAP & LOT INS I'ALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �f��( �4— (size) /00 NO.OF BEDROOMS BUILDER OR OWNER QNkIP17S PERMITDATE: SCE 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) r% Feet Furnished by ,4 AOi 6E 4c Commonwealth of Massachusetts w 14- Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Victoria Street Property Address Gabor.lLl eJrn7 Owner Owner's Name information is required for Centerville MA 02632 11/13/07 every page. CityTrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 9 �'a 1 only the tab key . Inspector: to move your Robert J. Bortolotti cursor-do not use the return Name of Inspector p�I ^1 ' 1 �l V l�' "I key. Bortolotti Construction, Inc. Company Name P. O. Bov 704-45 Industry Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-771-9399 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! -; 0 Needs Fu5rtb r Evaluation by the Local Approving Authority r= Inspector-s'Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments w 46 Victoria Street Property Address Gabor I-1' P Owner Owner's Name information is required for Centerville. MA 02632 11/13/07 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: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below: Comments: B) System Conditionally Passes: . ❑ One or more system components as described in the"Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement-or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. if"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound; exhibits-substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved.by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . i ND Explain: ❑ Observation of sewage backup or break out:or high static water level in the distribution box due to broken or obstructed pipe.(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•y''r 46 Victoria Street Property Address Gabor,f�4g`fu hild+ Owner Owner's Name information is required for Centerville MA 02632 11/13/07 every page. Cityrrown State Zip Code Date of Inspection - B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 CHAR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official( Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 46 Victoria Street Property Address Gabor M(arrQhQrJ- Owner Owner's Name information is required for Centerville MA 02632 11/13/07 every page. City/Town State Zip.Code Date-of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ 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 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 stems: Y pp Y You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to.an overloaded or clogged SAS or cesspool El ElStatic"liquid level in the distribution box above outlet.invert due to an overloaded. or clogged SAS or cesspool ❑ ElLiquid depth in cesspool is less than 6".below invert or available volume is less than %day flow ❑ Q 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. ❑ El tributary portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply: l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- 46 Victoria Street Property Address Gabor .P. Owner Owner's Name' information is required for Centerville MA 02632 11/13/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ❑ 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. t5insp•08/06 Title 5 Official Inspection 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 46 Victoria Street Property Address Gabor. -d Owner Owner's Name equiredd for on Is r Centerville MA 02632 11/13/07 requir every 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? N. ❑ 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•08106 Title 5.0fficial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Victoria Street Property Address Gabor I�4.eS r h Owner Owner's Name Information is required for Centerville MA 02632 11/13/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No y Poo Water meter readings, if available last 2 ears usage �� y 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current-yearround residence 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:. Last date of occupancy/use: Date Other(describe): t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts ' Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not-for Voluntary Assessments .°yr 46 Victoria Street Property,Address I- Gabor_MP.r u Owner Owner's Name�r information is required for Centerville MA 02632 11/13/07 every page. City/Town State Zip.Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 11/05- provided by homeowner 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) ❑ Tight tank. Attach a copy of.the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if,known) and source of information: '88 - provided by homeowner Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 115 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 46 Victoria Street Property Address. Gabor.( t^iV�fY1c�`�- Owner Owner's Name information is required for Centerville MA 02632 11/13/07 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): 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): Inlet 24" Outlet 40" 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: 8.5'x 6' x 5' Sludge depth: 411 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 6" Distance from top of scum to top of outlet tee or baffle a �r � t Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? physical observation t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts N Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 46 Victoria Street Property Address Gabor e-rru t� I Owner Owner's Name information is Centerville MA 02632 11/13/07 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet.and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): It's a 1000 gallon precast septic tank with inlet cover 24" and outlet cover 40"to grade, it has cement inlet and plastic outlet tees with 6"scum and 4"sludge at time of inspection - Pumped 1,000 gallons from tank immediately following inspection. i 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.): 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): t5insp 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Victoria Street Property Address Gabor Owner Owner's Name information is required for Centerville MA 02632 11/13/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Working Level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is 42"to grade and at working level at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachuse tts N w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 46 Victoria Street Property Address . �- Owner Gabor . --—-- Owner's N a m e j information is required for Centerville MA 02632 11/13/07 every page. CitylTown State Zip Code Date of Inspection. i 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: leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): It's a 1000 gallon precast leach pit with cover 28" and.top,of pit 48"to grade. Water level was 28" from top of pit at time of inspection with no indication of staining of it being any higher. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15. Commonwealth of Massachusetts v, W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Victoria Street Property Address Gabor M (` Owner Owner's Name -1 information is required for Centerville MA 02632 11/13/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): 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•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title .5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 46 Victoria Street Property Address Gabor, Owner Owner's Name requir do r Centerville MA 02632 11/13/07 required for every page. Cityfrown State Zip Code Date of 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. �-eckf- G l I 4 . 1000 Cce[l hJl l5insp-08/06 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form --Not for Voluntary Assessments M 46.Victoria Street Property Address GaborN� Owner Owner's Name information is required for Centerville MA 02632 11/13/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells l � Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record I If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ . Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ER Accessed USGS database-explain: You must describe how you established the high ground water elevation: �� , t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Permit Number: Date: Completed by: v'`v HIGH GROUNDWATER LEVEL COMPUTATION Site Location: Lot No. Owner: GI?ior Address: Contractor: Address: Notes: Q./g7ftS / /�GS , STEP 1 Measure depth to water table to nearest'1/10 ft. ............. df< 34 v G.......................... ................................... :Date: month/day/year STEP 2 Using Water-Level Range Zone :and Index Well Map locate site and determine: OAppropriate_index well............................. ✓�� 7-U OWater level range zone .:.:.. STEP .3 :Using Y monthl report"Current Water Resources Conditions" determine current depth to ��107 77 water level for index:well.......:.................... month/year STEP 4 Using Table,of Water-level Adjustments .:for index well (STEP.2A),current depth to water level for index well (STEP 3), and water-level zone (STEP 213) , y determine water-level adjustment ...... ...............................................................................: STEP 5 Estimate depth to high water by'subtracting.the water- level adjustment (STEP 4) from measured depth to water IDS level at site:(STEP 1) ............... . � Figure 13.--Reproducible computation form. 15 vt.• • pd 00 Checklist For Inspections Septic Tank. Size Gallons U Construction i.e. Pre-Cast,Metal etG Covers to Grade: Inlet 2. /�( Outlet '410 Tees (Plastic or Cement): Inlet Outlet k Scum Level Sludge Level Y`' Pumping Recommendations-if necessary. Measurements from Two Points of House to Inlet and Outlet Covers Town Of Barnstable needs Map, Lot and Parcel Numbers can be obtained at the Assessors's Office on.the First Floor: of Town Hall. Distribution Box: Working Level L How Beep in ground �- Measurements also needed from two points S.A.S. (Leach Pits, Flo Diffussors, Infiltrators, Cesspools, Stone Field) Size hold Gallons Construction i.e. Pre-Cast, etc. �e Top Of Cover and Top Of Pit i `ate�' .� l ,'S �� Water Level'`2 -f AV a;P o,f' )a,,,(- Note Indications of Staining if Higher than Water Level (Such as if the Component shows it has been full at one point in time). NOTE: Also mark out on Drawing if it is the Front, Back, Right or Left Side of Building where Inspection was done. Also -if the system:if made up of Cesspools, note whether if they are Single Cesspools or if they are set up as.the Main Pool and a Overflow, also note their physical condition. r 100. O ! j _.__ IF dap Tic el 1��� adlSelo i Town of Barnstable �p tHE Tp� Regulatory Services B,, SIAB Thomas F. Geiler,Director 9� �9. •�� Public Health .Division Arfp�,�A Thomas McKean,Director 200 Main Street, Hyannis, MA 02661 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. I r COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS W DEPARTMENT OF ENVIRONMENTAL PROTECTION a` d gV `)ARCM 'b TITLE 5 - '- W OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 46 Victoria Street LHEALTIHI'DE]PT. Centerville MA 02632 Owner's Name: Kimberly CazeaultOwner's Address: Same 2vember 1 2004 ANf Ins ection: No Date o p Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: 0%Nt11111 OF _XX_Passes �� •• �' �'� Conditionally Passes ••'yG Needs Further Evaluation by the Local pproving Authority _ F ' s '�i El. Inspector's Signature: Date: 11/O1/2004 ,� '•. F`�o.•�Q. SIN The system inspector shall submit a copy of this ins ection report to the Approving Authority(Board of Hsi i.ttN���� DEP)within 30 days of completing this inspection f the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owners iall submit the report to the appropriate regional office of the DEP.The original should be sent to the system own r and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Observed liquid level in le Ching pit 2' below inlet pipe with a high stain 2"above current level.Recommend pumping tank in one ear and every two years to properly maintain system. ""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 s stem will perform in the future under the same or different conditions of use. i I Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM— OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ART A CERTIFICATION (continued) Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 Inspection Summary: Check A,B,C,D or E/ALNN AYS complete all of Section D A. System Passes: _XX I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replace nent or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltratio 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 struc urally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out o high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or unev n distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution boxlis leveled or replaced ND explain: I The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titles G incnartinn 1~nrm Ail r,iinnn 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 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 15.3030)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Titla G Tnenartinn Rnrm All r%11()()() 3 Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 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 _ _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. IThis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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. T41A G Tncn-rf;- P—f111 ci')nno 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks'? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS, located on site? 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: Yes no 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(3)(b)] Titla Tnenartinn T:nrm /15/7Ml1 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): .Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2002—155,000 gal.2003—116,000 gal.=371 gpd.* Sump pump(yes or no): No ** water usage includes irrigation system. Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Pumped one year ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Tank installed in 1983 new leaching pit installed in 1990 Were sewage odors detected when arriving at the site(yes or no): No Tlt1.G Tncnortinn Pn 411 si)nnn 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 BUILDING SEWER: XX (locate on site plan) Depth below grade: 4' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 25' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 4' Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5' long x 5.8'wide—1500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,liquid level at bottom of outlet pipe. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titla C Tncnartinn Fnrm Aii r,nnnn 7 Page 8 of 11 OFFICI AL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): No solids or high stains present. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I I Titles incr�artinn Fnrm�ii v�nnn 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6(1000 gal.)pit. 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.): Liquid level in pit is 2' below inlet pipe with a hieh stain line 2"above current level. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Title G Incnortinn Anr 411 r,11nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 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. Victoria Street 3Z Wl. qy 5� 1500 gal tank 1000 gal pit Ti11a S Tncns+�r:nn Fnrm till v�nnn 10 f Page I 1 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Victoria Street Centerville MA 02632 Owner: Kimberly Cazeault Date of Inspection: November 1,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 15 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.35 and topo map shows property above el.50. Bottom of SAS is 9' below grade leaving more than 6' separation between groundwater and SAS. T41. 9i..e.iurtinn Fnrm 411 crnnnn l 1 PER j-F COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 46 VICTORIA ST. CENTERVILLE Name of Owner n/a Address of Owner: JIM PHILLIPS Date of Inspection: 2/2/99 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 Telephone Number: (608)564-6813 CFRTIFICATION 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: X Passes Conditionally Passes _ Needs Further Eval ti n By the Local Approving Authority _ Fails Inspector's Signature: �i Date:2/3/99 The System Inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS'S TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 VICTORIA ST.CENTERVILLE Owner: n/a Date of Inspection:2/2199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. KID The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is 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 complying septic tank as approved by the Board of Health. NII 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 NO 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 obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 VICTORIA ST.CENTERVILLE Owner: n/a Date of Inspection:2/2/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n/a(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 46 VICTORIA ST.CENTERVILLE Owner: nla Date of Inspection:2/2199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 VICTORIA ST.CENTERVILLE Owner: n/a Date of Inspection:2/2/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. 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 septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) ]t 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9l2/98 Page 5 of 1[ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 46 VICTORIA ST.CENTERVILLE Owner: n/a Date of Inspection:2/2/99 FLOW CONDITIONS RESIDENTIAL: Design flow:,g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):nLa Total DESIGN flow: Number of current residents:$ Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): MQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): 11IQ Last date of occupancy: n& COMMERCIAL/INDUSTRIAL Type of establishment: nta Design flow: n&gpd(Based on 15.203) Basis of design flow: D& Grease trap present:(yes or no):JW Industrial Waste Holding Tank present:(yes or no): Na Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:nLa Last date of occupancy: n& OTHER: (Describe) Wa Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: NOT IN FIVE YEARS System pumped as part of inspection:(yes or no):MQ If yes,volume pumped nLa_ gallons Reason for pumping: n& TYPE OF SYSTEM XSeptic tankidistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: Wa APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM IS 14 YEARS OLD WITH A NEW PIT INSTALLED 5 YEARS AGO. Sewage odors detected when arriving at the site:(yes or no): MO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 VICTORIA ST.CENTERVILLE Owner: nla Date of Inspection:212/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 4'6_ Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: jVA Comments: (condition of joints,venting,evidence of leakage,etc.) n/a SEPTIC TANK: X (locate on site plan) Depth below grade: 4 Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): DLO Ida Dimensions: 16'6"H 5'7"W 4'10" Sludge depth: E Distance from top of sludge to bottom of outlet tee or baffle: 3, Scum thickness: 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: Jr How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEM MAINTAINED EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Wa Dimensions: Wa Scum thickness: n1a Distance from top of scum to top of outlet tee or baffle:— Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: Wa 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.) t revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 VICTORIA ST.CENTERVILLE Owner: n/a Date of Inspection:2/2/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: nta gallons Design flow: nLa gallons/day Alarm present: NO Alarm level:ji& Alarm in working order:Yes_No_: NO Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wit DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) ElLa PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 VICTORIA ST.CENTERVILLE Owner: n/a Date of Inspection:2/2/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: jiLa leaching galleries,number: jVa leaching trenches,number,length: WA leaching fields,number,dimensions: nLa overflow cesspool,number: n& Alternative system: n& Name of Technology: j3& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY PIT WAS 1/2 FULL AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: Wa Depth of scum layer. nLa Dimensions of cesspool: nLa Materials of construction: nLa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)D& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:WA Dimensions:n& Depth of solids: D& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SPYSTE C INSPECTION FORM SYSTEM INFORMATION(continued) Property Address: 46 VICTORIA ST.CENTERVILLE Owner: n/a Date of Inspection:212199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a Dee rj A A �P� DA i rev ised 912/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 VICTORIA ST.CENTERVILLE Owner: n/a Date of Inspection:2/2199 NRCS Report name: nLa Soil Type: nLa Typical depth to groundwater: nLa USGS Date website visited: n& Observation Wells checked: IYQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records Checked local excavators,installers XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 y TOWN OF BARNSTABLE LOCATIO/N� SEWAGE # VILLAGEC�AA�auo SESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.` 6 b _ m if-cla SEPTIC TANK CAPACITY r0 LEACHING FACILITY:(type) t (size) C ' � NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER - - BUILDER OR OWNER DATE PERMIT ISSUED: �p DATE COMPLIANCE ISSUED: l� U VARIANCE GRANTED: Yes No �-I�� Q�� i No11.... (1. Fis...�� �... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE firtttiun for Dig uiitt1 Workii Tomitrurtiun lbrmit Application is hereby made for a Permit to Construct ( ) or Repair (individual Sewage Disposal System at: , L cation- ddress or Lot No. Owner ddress a ............ .... ..�:> ...............:P _y.16 ..... ....... �4 � Installer Address UType of Building Size Lot............................Sq. feet .-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e� yp of Building ____________________________ No. of persons._..._______.._____.._______ Showers ( ) — Cafeteria ( ) dOther fixtures .----•-----•-----------------------------------------------••----•--------------------- W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity......._....gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width...................:Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------- Diameter..../-..C....... Depth below inlet... .._......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................---___- IxI •-------------------------------------------------------------- --.------------------------------- ---------• ------------------------• --------------------- 0 Description of Soil........................................................................................................................................................................ x c, ------------•-•-•---------------•--•--------•-----------------..............................................................••--------------.....----......------------.........---••----.........---- UW ------------------------•...----•-----------•-------------------•------------•--------=-••••------•------------------------•---------- Nature of Repairs or Alterations—Answer when applicable...__."-GNP_ . __...-.V: ------P"----------------------- }� tV �'►T --------------------------------------------------------------------.......-------------•----------•--------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com liance has been issued e board o health. Signed Application Approved BY ----------- ---------------------------------------- ------- �V--Y-0 Application Disapproved for the following reasons• ---------------- ------ ------------------------------------------------------------------------- ------------------------------ ------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- ------ ---- --------- ------------- Bum PermitNo. ................................. Issued .--- --------------....--.....---- Dace �pp N0...9,?::: � 1 Fss....-5�....... ...... b tz Sty-�-e +" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ' � Aplifiratiou for Uhipasal Works Tonstrur#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( t..)—an Individual Sewage Disposal System at: l//__� ................L_.l Y .... _�.G !!z ae � Location•Address or Lot No. �1 �i. . j.� �� b ..................... - _ Owner ` a ....................... _..�. ��....C C�— ---------•-- ----•--•------•-- . n.... C?u tldd`r<< \�_....... .. .�`.�__. ..Installer Address c Type of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms............................................Ex Expansion Attic a — p ( ) . Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons..................._........ Showers ( ) — Cafeteria ( ) dOther fixtures ••--••--•-----••••-•--•••-••--•-•--•--•-•--•----...••.-•••---------••-----•----••----------------•----....••-•••--•-••....-----•-•-•-----------...... W Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.............._.,Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area____-__•--_-------sq. ft. Seepage Pit No......../........... Diameter..... 172_..._. Depth below inlet....Z`?_......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ 14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-................. P4 ----------------------------------••----•-......._........••••-•---......-------••••---•-•-••---••----------•---••••-------••--......................••---,-- 0 Description of Soil.......................-....................................-•....---••--•--------------------•-•-------•••---•---••----------------•---------------------••-•----••=-. x w x U Nature of Repairs or Alterations—Answer when applicable_..... _�!4 ......_.!.CZ ....._E7S ---..................... ` t .. ..................••-••-•-•-•------•---•...-••------...•--•••••-----•-•--....----------•-••---•-----....-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal'System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the . system in operation a Certificate SfgCodm liance has n issued�,\board of health. /-! Y p ....... issued Y % - 1•. ,C�.�!• Date A''iplication Approved By........ ........l�Gr ? 1 .. - �: � to Application Disapproved for`the following reasons: ------1...-^----- ...................................- .................-_................-.................................------ , l '# Date Permit No. .------. 1................. Issued ------------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , C�ez#ifi�tt#e �rf CZnm�itttr>:�.e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( L_)..• by ...................................... ..1 ..��C , .-............----.............------......--...---........'........................................................ Instal er { at ............:.................................... ...... �Sa ,. ...✓•�-....... T' — .... has been the application installed in accordance with the provisions of TITLE 5 of TheState Environmental Code as described in for Disposal Works Construction Permit No. ..— .................... dated --// 'U----....------..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �a DATE - I1 f Inspector - v ........�.. - '_............. .... t . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No..(ql -.��' !� TOWN OF BARNSTABLE FEE... ............ Disposal Works Tonstrrudivit "Vrrutit Permission is hereby granted.............. . . f ..... ,..1 Win....._....``.fa_T ...... to Construct ( ) or Repair ( �)_an-lndividual Sewage Disposal System atNo.............. ��'l `�y ...........S.:K....................................................................................... ................... Street as shown on the application for Disposal Works Construction Permit No.G?0.s53 . Date :*.1,A.*. .az2 �O Board of Health DATE.. l ---•--•----•-•••--. / FORM 36508 HOBBS a WARREN.INC.,PUBLISHERS t 7C' ATION SEWAGE PERMIT NO. Lot 35 VictoriaLAGE INSTA LLER'S NAME i ADDRESS Robert B. Our Co. Inc. li Great 6VJestern d. North Harwich, Mass. 02645 BUILDER OR OWNER Louis Gordon ^ DATE PERMIT ISSUED '\-,-DAT E COMPLIANCE ISSUED /;�'/S11-1 �� �`� � � � . a6 ` FINISH GRADE OVER D-BOX= 54.0'± PROP. VENT WITH CHARCOAL FILTER TO ABOVE GRADE _T T.O.F. EL.= 5 5.0 ± FINISH GRADE OVER CHAMBERS = 53,$' - 54.2' GENERAL NOTES PROVIDE EXTENSION RISER REMOVABLE WATER-TIGHT COVER OVER SLOPE @ 2% MIN. OVER SYSTEM 3/4"TO 1-1/2" DOUBLE WASHED WITH COVER OVER INLET& RISER TO WITHIN 6" OF FINISHED GRADE 4" SCHEDULE 40 PVC STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE OUTLET TO WITHIN 6" OF F.G. 0 INSPECTION PORT WITH ACCESS BOX METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL @ FND. EL.= 54.3 ± F.G. OVER TANK EL. = 54.6 ± 5' DIA. OUTLET(S) MIN SLOPE 1 /o TO F.G. (SEE GENERAL NOTE#21) 2 OF 1/8 OT X DOUBLE WASHED CODE AND ANY APPLICABLE LOCAL RULES. r STONE OR GEOTEXTILE FILTER FABRIC� 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE I I PLACE RISERS ON ALL DESIGN ENGINEER. PROPOSED 4" 3.5' MAX. 4 0' MAX TOP OF SAS = 50.20 CHAMBERS WITH EXISTING 4" SCH. 40 PVC SEE NOTE 23 49.20' SEE NOTE 23 , INLET PIPES TO 6" OF 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SEWER PIPE =i=j�_ SEWER PIPE BREAKOUT EL = 49.70In, FINISHED GRADE SYSTEM UNLESS OTHERWISE NOTED. 3" DROP MAX L=2T+ 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 6 3 2" DROP MIN 3 9 PROVIDE WATERTIGHT ELEVATION =49.70' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A 13" 4" PVC IN FROM ,-----JOINTS (TYP.) \-*rj0.Cj'-� SEPTIC TANK 4" PVC OUT TO 0 O ��� 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF 14 0 0 0 O 0 a o THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. CONTRACTOR TO PROVIDE • LEACHING FACILITY ao � o 0 SPECIFIED DROP BETWEEN o o o 5. SLOPE ALL SOLID PIPE AT 1.0/o MINIMUM. INLET AND OUTLET CONTRACTOR CONTRACTOR SHALL i , 12" 6" o0 0 0 OUTLET TEE 49.50 MIN. 49.33' 2' 6, THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48" VERIFY CONDITION OFAND \ 0 0 o o oCo EXISTINGDIEPT STION EPTIC AND RING TEESEPLACE AS ( GAS BAFFLE 6" CRUSHED STONE °° o 0 00 7 LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK OVER MECHANICALLY o0 0 0 0 o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS TANK NECESSARY COMPACTED BASE 4.0' (TYP)85 NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH AND DESIGN ENGINEER. . ' I 4.0' OUTLET DISTRIBUTION BOX TO BE INSTALLED ON A LEVEL STABLE 5' (TYP-) 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 54.27' 2 ESTABLISHED ON THE CORNER OF THE BULKHEAD AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET ZA7 2O' GROUND WATER ELEV.- < 42.00' PIPES TO BE LAID LEVEL. 12.83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK 2 - 500 GALLON H-20 CHAMBERS 5' MIN. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT FY EXISTING CROSS SECTION VIEW ,ry CHAMBER END VIEW 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES ELEVATION TPRIOR O OR TO ANY WORK& SEPTIC TANK PROEILL H-20 DISTRIBUTION Ux UETAIL TYPICAL CHAMBER PROFILE CHAMBER ()� 1-AILS TO THE DESIGN ENGINEER. NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE I NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. _ 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM f ` � • ' • PERC NO. TPT-19-139 APPROPRIATE AUTHORITY. �`Q- ' ' •, + • �Q INSPECTOR: David W. Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED ' • ' ` • • ' + ,�� UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR �\ ••* ` ' + +. • • . / EVALUATOR: Michael Pimentel, EIT, CSE TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING. Z - C.S.E. APPROVAL DATE: Oct, 27 1999 --- ttC'- • • '' ('` "'b ,` ��` 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. II ~, ; ` • +r', t� DATE: September 6, 2019 MAP 148 11 • • • • • •+ ' •• TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE LOT 65 EXISTING 1,000 GALLON + • • 1 MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. `� , �.��,, • „/ \ I N/F O' SULLIVAN TANK TO BE UTILIZED IN q� • f• • �; + �Y {, /,' .' ELEV TOP = 54.00' REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, C FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.2 . 39'56'E ) _ � S84° � THIS DESIGN *�: • �• ; •: " f: `- ELEV WATER= <42.00' 55(3) ( t`i f'• • �• 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN 84.55' . •• • • PERC RATE _ <2 min./inch SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. kN S81°58,30„E ,/ fI w• • Q DEPTH OF PERC = 36"-54" 16. PROPOSED PROJECT IS LOCATED WITHIN. 78-18' TEXTURAL CLASS: 1 �� ASSESSOR'S MAP 148 LOT 64 r f j I - - --- 14" ci.VCE(j yP �\ a ,I OWNER OF RECORD: GABOR MENYHART Z LTI ' w C i ~ o SIT. DECK20 ) / M �� " * • !/ ADDRESS: 35 Abegale Snow Road GARAGE N \� o r ,1 n I °'- o DRIVE 54x6' y Y �f8 rry J/ . 0 54.00 WEST BARNSTABLE, MA 02668 __j ! cn o ' 54x8' �� p (/ A Loamy Sand m LOCUS // 10Yr 3/1 FEMA FLOOD ZONE X Dj I �� / EXISTING LEACHING PIT TO BE • 6' 53.50 m I i - - -- -- PUMPED, FILLED WITH CLEAN Z `:� r'*', I! ' COMMUNITY PANEL# 25001CO561J I COARSE SAND &ABANDONED L _______ - g Loamy Sand W \ POOL Z ,nr, •" 17. DEED REFERENCE. DEED BOOK 19414, PAGE 105 -- ( SUN j }- o -ROX. LOCATION ONLY? T . • 10Yr 5/6 AS CAS r \ ROOM LP BECK , w 1� 36' 51.00' 18. PLAN REFERENCE: PLAN BOOK 350, PAGE 55 0 7o I AS q #46 \ MAP 148 � ' ' ' m I�� \ EXISTING O i a' 1\ m _ -�, ;� = r n rry ` • 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. \ 3-BEDROOM APPROX. o LOT 67 ,. i r y ', / •• • -' I\ \ SWIMMING N/F HURLEYbe ` 49.50 20 PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY wv -W DWELLING D-BOX C, _ / r bQ r� •• „ •' w-�\ PROP. j/ \ POOLLO %� /-"- i �f�l ,' FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY I, \ TOF- + H-20 LO L ___- I , -� -y ' . FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. MAP 148 I ( _ Med.-Coarse Sand -55.0_ D-BOX t\ EXISTING LEACHING PIT TO BE 23 _ f , • • % ' i' l C C 21. A 4" PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A v 1 LOT 64 I '' . 1 • /" / 2.5Y 6/6 ,� I PUMPED, FILLED WITH CLEAN ` \ _ !� • f �/ DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3" OF FINISH GRADE. A f o i 15,404±S.F. ) 11.0' 'l "-'.. I COARSE SAND &ABANDONED �� Q ,°, REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. rn'n TP 1 � GARDEN + pl r /( CHIM. TP 2 O O 54x0' I x (APPROX. LOCATION ONLY) n 22. CONTRACTOR SHALL BE RESPONSIBLE TO OBTAIN ANY AND ALL REQUIRED PERMITS AND -n l 54x0'-y. 54x6 ( I / S PROPOSED 4" PVC VENT APPROVALS FOR THIS PROJECT. � � )j LOCUS PLAN _ APPROVALS ARE REQUESTED FROM 310 CMPIPE- EXACT LOCATION 23. IN ACCORDANCE WITH 310 CMR 15.401 -15.405, THE FOLLOWING LOCAL UPGRADE rn I { / N, t ;<-X-X--X-X-X � X PER OWNER R 15.211 & 15.221 (7): SCALE: 1"= 1000' (1.) A 9.0'WAIVER (20.0' - 11.0') FOR THE SETBACK FROM THE SAS TO HOUSE FOUNDATION. �I �1 / \ N86° 13' 10"E 144" 42.00' (2.) A 0.5'WAIVER (3.0'-3.5') FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX. 160.00' �FENCE No Mottling, Standing or Weeping Observed (3.) A 1.0'WAIVER (3.0'-4.0') FOR THE MAXIMUM COVER OVER THE SAS. _ Benchmark (TYP ST�� ��� � ��A SWING-TIES Nail In 16" Pine PROPOSED (2) 500 GALLON LEGEND Elevation = 54.2T MAP 148 H-20 LEACHING CHAMBERS DESIGN DATA PERC NO. TPT-19-139 DESCRIPTION HC-1 HC-2 Approx. M.S.L. LOT 63 PROPOSED INSPECTION PORT NUMBER OF B INSPECTOR: David W. Stanton, R.S. 50xO' EXISTING SPOT GRADE N/F WOJKOWSKI BEDROOMS (EXISTING) 3 CORNER OF STONE (1) 11.0' 23.6' EVALUATOR: Michael Pimentel, EIT, CSE NUMBER OF BEDROOMS (DESIGN) 3 50 ------ EXISTING CONTOUR CORNER OF STONE (2) 35.9' 31.2' DESIGN FLOW 110 GAUDAY/BEDROOM C.S.E. APPROVAL DATE: Oct, 27 1999 r� CORNER OF STONE (3) 38.6' 41.6' TOTAL DESIGN FLOW 330 GAUDAY DATE: September 6, 2019 PROPOSED CONTOUR TEST PIT#: 2 F5_0__j PROPOSED SPOT GRADE CORNER OF STONE (4) 17.9' 36.3' DESIGN FLOW x 200 % = 660 GAL/DAY ELEV TOP= 54.00' GAS EXISTING UNDERGROUND GAS USE EXISTING 1,000 GALLON SEPTIC TANK ELEV WATER = <42.00' --- --- EST/C - EXISTING UNDERGROUND UTILITIES PERC RATE = W W EXISTING WATER LINE INSTALL 2 - 500 GAL. CHAMBERS w/ AGGREGATE DEPTH OF PERC = TEST PIT LOCATION SIDEWALL CAPACITY TEXTURAL CLASS: 1 (LENGTH + WIDTH) (2 SIDES) (2' HIGH) (0.74 GPD/S.F.) = GAUDAY - O O EXISTING 1,000 GALLON SEPTIC TANK (25' + 12.83) (2 ) ( 2' ) ( 0.74 GPD/S.F.) = 112 GAUDAY 0" 54.00' PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE Loamy Sand GARAGE DECK BOTTOM CAPACITY A 6„ 10Yr 3/1 53.50' ❑ PROPOSED H-20 DISTRIBUTION BOX (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAUDAY (25'x 12.83) (0.74 GPD/S.F.) = 237.4 GAUDAY g Loamy Sanc O PROPOSED 500 GALLON H-20 LEACHING CHAMBER 10Yr 5/6 36" 51.00' SUN TOTALS: REV. DATE BY APP'D. DESCRIPTION #46 ROOM C-2 TOTAL NUMBER OF CHAMBERS 2 PROPOSED SEPTIC SYSTEM EXISTING TOTAL LEACHING AREA 472.1 SQ.FT. UPGRADE 3-BEDROOM TOTAL LEACHING CAPACITY 349.4 GAL./DAY DWELLING = 1) 2) C -Coarse Sand TOF 55.0'+- Med. PREPARED FOR: NOTES: 2.5Y 6/6 CAPEWIDE ENTERPRISES 1.0' 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF LOCATED AT EACH SEPTIC SYSTEM COMPONENT. HC- ~O 46 VICTORIA STREET 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE ` CENTERVILLE MA 02632 :��;{ ..:;:�:••:;.,:... PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST PIT , DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF SCALE: 1 INCH = 20 FT. DATE: SEPTEMBER 30, 2019 3) HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. 144" 42.00' tN Of �N 1 11 21 41 81 FEET (4 No Mottling, Standing or Weeping Observed 3.) ENTIRE PROPERTY IS LOCATED WITHIN THE GROUNDWATER JOH ��' PROTECTION OVERLAY DISTRICT AND THE ESTUARINE WATERSHEDS. N L. PREPARED BY- RESERVED RESERVED FOR BOARD OF HEALTH USE I CHURCHILL JR. a, CIVIL JC ENGINEERING, INC. 4.) SWING TIES SHOWN ON THIS PLAN ARE PROVIDED ONLY AS A COURTESY NO. 41807 2854 CRANBERRY HIGHWAY FOR THE INSTALLER. INSTALLER SHALL VERIFY SWING TIE MEASUREMENTS IN THE FIELD PRIOR TO INSTALLING THE SYSTEM. CONTRACTOR SHALL , EAST WAREHAM, MA 02538 SWING-TIES PLAN SITE PLAN NOTIFY ENGINEER IF MEASUREMENTS APPEAR TO BE INCORRECT. 508.273.0377 SCALE: 1"=20' SCALE. 1 -20 Drawn By: ATB Designed By:MCP Checked By:JLC JOB No.4812 �c No._ - F$$_ D THE COMMONWEALTH OF MASSACHUSETTS ID�I' BOARD OF HEALTH .............oF....... -?.BL '"...----•-••-•--..........._. F Appliration for Disposal Works Tonstrurtinn ramit r; - F Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal jSystem at: .............. .................... ..................................... Location-Address or Lot No. ................---------------—----------.._........_..........._.._........ — -•------------=---•-•--•--•---••-•--•--•---•-------•.............---..._.---- W Owner Address a ....--•-----...--•••-....-------•-•••-----------•-------•----••--•-----------••-----•-------... ----- . --------------------------------- .. .... Installer - Address Type of Building Size Lot-•-_--------_-_--. -.--.-Sq. feet .� Dwelling—No. of Bedrooms..........0.................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Buildin a yp g ............................ No.No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures - . ................... ..................................:.......................... Design Flow...........J`r___S......... ..:.......•gallons per person per day. Total daily flow...........3 .0•-----______--_---gallons. Septic Tank—Liquid'capacitylP��gallons . Length.-.4q..'.. Width...¢_ .._. Diameter................ Depth..... ..!- Disposal Trench—No..................... Width.................... Total Length----------------___. Total leaching area...................sq. ft. Seepage Pit No......._/----------- Diameter-f9c.,5.`._. Depth below inlet..._6!:4...... Total leaching •area-5 ----- • tl"�• - z Other Distribution box (h) Dosing tank Y Percolation Test Results Performed by- 4-0�?_... ......�`'' _4-G ...-�:M<tr Date....--vim=1__`_�--�0 ._..__.. a Test Pit No. 1----!.! minutes per inch Depth of Test Pit-10 ...... Depth to ground water!v4 c.__. ." (x, Test Pit No. 2----------------minutes per inch Depth�of Test Pit.................... Depth to ground ODescription of Soil................---��---.... `'� ................................................_-----------------------.-----------------------------_... x _ tx ...................----••----------•-------•••-----•----•----•------•-•-•-----••....................................................................................................................... 1 U Nature of Repairs or Alterations—Answer when applicable................................................... .................•........................ -------•---------------------------------------------------------------•------------------•-------------•-••-----••---•---- E Agreement: t 9 ! The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in ' operation until a Certificate of Compliance has been issued by the board of health. ed ---------------------------------------------------------------------•......•--•- --------- Ithelollowing t date Application Approved By ---=------------------------------------------------------------------ _..�.:t�l_/-�------------ •Date__...__»» Application Disapproved f reasons________________•.--------------•-•----------------------_._.-_--_-.__.___ - ---------•--------------••---•------------------•-------•----•----------•-------...----------------......_..-------•------•-----•---------------............---•-•......--------•--- ------------ Date ---- PermitNo---------------------------------------------------»._ Issued--.................................................-- + Date .• Fi No nc............................. a';547-150 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF.......011ee44�`--77 4 ............................. Appliration for Disposal Works Toustrurtion Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: bv 4.i ra4elA , S7% ----7- --------------- ........ -------------------- ----------------- . ..................................... Location-Address or Lot No. —--------------------- .............................................. .......................................................A.......................................... ---------------- 6;ner Address Installer Address Type of Building Size Lot.............................Sq. feet U Dwelling—No. of Bedrooms.___.___.._ .3............................Expansion Attic Garbage Grinder ( ) 4 04 Other—Type of Building ........................... No, of persons____________________________ Showers Cafeteria ( ) Other fixtures. ....... ............................................7..................................... .......... .............w........................... Design Flow...........45'T......................gallons per person I per day. Total daily flow.___._._ ..................gallons. ..... ........ . 9 Septic Tank—Liquid capacity/474?4?gallon.s Length....4 .. Width__.4-7# . Diameter.___.:_ Depth....-4- 11 Disposal Trench—No_ ____________________ Width.................... Total Length.........*............Total leaching area....................sq. ft. Seepage Pit No-------- ---------- Diameter./Pt.�9.4.., Depth.below inlet.....4 ......... Total leachinz area.5- --c P,0 Z Other Distribution box (71), Dosing tank 0-4 Percolation Test Results Performed by- .............. Z"� Date....9�nLl:!!: .......... . Test Pit No. I...."5-_q Zminutes per.inch. Depth of, Test Depth to ground water �-4 --Xi?44-, �T4 Test Pit No. 2................minutes per inch Depth,6A,Test Pit.................... Depth to ground. wate.,jZWW-,k.'1A.,....-------A= ........... .................. ................................................................................................................... 0 Description of Soil............. ......... ....._..I--------.................................................................I.................................. U .......................................................................................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 TLITIL, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ned.,.................................................................................... .... /.............. te Application Approved By...........I .... ............................................................................... . ............. Date ing Application Disapproved fo Ithelollowing reasons:............................................................................................................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (Intifiratr of Toutpliattrr TV IS TO CERTIFY, That the Individual Sewage Disposal System constructed (��r "Repaired .......... ----------- ----------- - -------------- b3 -.4--w—Y.......... ............................................................................................ rn—staller ............. . ....... .........I................................................................ Xc.....- has------ - ---------- ............. has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Cod as r scribe in the as scribed . ..application for Disposal Works Construction Permit No.--13.4_3(f .- . . ................................. dated- THE ISSUANCE 0 ZANTEE THAT THE ,VTHIS CERTIFICATE SHALL NOT BE CONSTRUE® AS U SYSTEM WILL ON SATISFACTORY. DATE......!f:.T ......... .............................................. Inspector...... ........ ................................................................../ ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................. ...OF................................................................................ FEEJV V............... Disposal Works %T.11notrudion frrmft Permission is feby granted.....CkA.,_...................................................................................................................... to Construc or e it (p an divilual ,a/ Disposal System atNo.Ile------ ----------- ...... .... ......... ..................................................---------------11_/.... ............. Street as shown on the application for Disposal Works Construction Permit No_____________ at ?'- :- .__....._. 41- ................................. ... . ... ................................................ Board of Health �DATE...a............................................................................ FORM 1255 A. M. SULKIN, INC., E30STON