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0165 WARWICK WAY - Health
165 WARWICK WAY, CENTERVILLE e ✓ q ",� .is t:.r:y'y.•. b.o x7-td t r l� - -'GOG'ATIOE.i: G'.�iC/?�•��G4.Ee /✓t'�55_ , ._ -_�':: � . :..c�... , ' G e T .3S .ccA.t/ IBoorC 28/� PiT �Tf•�'/'BF WRSf�Ec�.:37?a::��' Z H�G�EBY CE'G�T/FY T T!� /LD/atJGw _ '.-,,'r :•4. °��h�o�.c! owv r,�•��S PGgA,/ is GacA Ea N THE _ ''� -_- . AS vadOWiV q D T qT iT J;�t_-s co.vFof�n.� r+o Ts-� .z ,vG �,�'^-�{' \ ';'�•.- .. . ©Y---GRWS o.- TNC- 7vw.v OF ta>'W av caysT.euc 7--E a_ ARWE-:r •.- GC1i.A! �'��� �.'P"►�/i'7e�'i^lf'7 .�� o c dJAIA' �� x�i��= `�� . '•' #26 a = - c/V�L EAIG%�C/EEB$ � : - }�f n�,�'( �I^� ff _ ••-:. . .I•.. � I—-s//T C/wn.IGVr..•-a c_ � ..��I� 1' .. .w.•�1.C/f�+r�'�..�l�� ��t. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 165 Warwick Way M Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information When forms the I �� computer, r, use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name tQ P.O>Box 763 Company Address Centerville Ma 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority , 9A?- k- 4/29/2009 " Inspector's Signature Date �y The system inspector shall submit a copy of this inspection report to the Appr ving Authbrity`(Board of Health or DEP)within 30 days of completing this inspection. If the system i a shared'system or has a design flow of 10,000 gpd or greater, the inspector and the system ow er shall 5ubmifithe report to the appropriate regional office of the DEP. The original should be sf nt to thQystAri owner and copies sent to the buyer, if applicable, and the approving authority. IrTa ****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. I l� t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: 1 D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface'Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist r Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® - Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank,and two leaching pits. Number of current residents: 0 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 165 Warwick Way M Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 6" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 165 Warwick Way M Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum'to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box not present. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.First leaching pit has been full was dry at time of inspection.Second leaching pit stain line was 32" below invert also dry. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map SizeJIM zoom Out _ In .`l t / YR* .a3 7fi 3 4 n rc3Yi ✓l;� a �-,.. F i u e�a rN YLL it 14,171,Y . R l k t Feet Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER (`nrnFrinhf 9nnFAnnA Tn..m of Rnrnefohic UA All rinhfe rcecnn http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=148115&map... 4/3 0/2009 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Bottom of leaching 28.6' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 165 Warwick Way Property Address Cape Cod Real Estate (Bank Owned) Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information--Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ,� mot■■ttt� - - — ___...,.._..• _. .._._ .-...._.__�..� s COMMONWEALTH OF MASSAC1 USE'ITS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a t.J TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 11711.5 Property Address: 165 Warwick Way Centerville Owner's Name: Stephen LOZZi Owner's Address: 429 PrinnP Hinckley Road �^ Date of Inspection: 7 120a g I t to j � gip! Name of Inspector: (please print)_:Sean Jones Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville. MA r� Telephone Number: (5081 779-f1776 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the infonnation 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 aot a DEP approved system inspector pursuant to Section 15340 of Title 5(310 Cl\1R 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa' Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health'M 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 repott to the appropriate regional office of the DEP.Tltc original should be scat to the system owner and topics sent to die buyer,if applicable,and the approving authority. Notes and Comments '"'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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 165 Warwick Way Centerville Owner: Stephen Lozzi Date or Inspection: 6006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.' Syy tem Passes: L 1 have not found an information which indicates that an y of the failure criteria described Y tn310CMR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: II. 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. ND explain: Observation of sewage backup or break out or Iugh static water level in the distribution box due to broken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)arc replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 canes a year due to broken or obstrt.-ctcd pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: f P. 1 Page 3 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 165 Warwick Way Centerville Owner: Stephen Lozzi Dale of inspection: C. Further Evaluation is Required by the Board of Health: /VIA Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Z. 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 front 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 Gee 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. Outer: 3 Page 4 of I 1 OFFICIAL INSPECTION FOIIAI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Properly Address: 165 Warwick Way en ervi e Owner: Step en Lozzi Date of Inspection: V1.471,7006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of die following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface wa(crs due to an overloaded or / clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than',day flow Required pumping more than 4 times in the last year NOT due to clogged of obstructed pipe(s). Number of times pumped_. Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is wittin a Zone I of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a pHvatc water supply well with no acceptable water quality analysis. (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 (lie presence of ammonia nitrogen and nitrate nitrogen,is equal to or less titan 5 ppm, provided that no other failure criteria are triggered.A copy of(lie analysis must be attached to (Iris form.l (Yes/No)The system fails. I have determined(fiat 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: ,/1��� To be considered a large system (fie system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the folio"ing: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface dr4ddng water supply _ _ the system is within 200 feet of a tributary to a sorface drinking water supply the system is located in a nitrogen sensitive area(Interun Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Scctinn E die system is comidered a significant ducat,or answered "yes'in Section D above the large system has faikd.The owner or operatar of arry large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNIR 15.304.The system oh%rer should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 165 Warwick Way Centerville Owner: Stephen Loz z i Dale of Inspection: - d oo6 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 7 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) r _ Was the facility or dwelling inspected for signs of sewage back up 7 ✓ _ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS, located on site 7 _ Were the septic tan{: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 Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)j 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 165 Warwick Way Centerville Owner: Stephen Loz z i Date of Inspection: T/3/3 -74 o z ar FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bedrooms): 3-,k) PO Number of current residents: 3 Does residence have a garbage grinder(yes or no):Na Is laundry on a separate sewage system(yes or no):/-'-' [if yes separate inspection required] Laundry system inspected(yes or no):fir Seasonal use:(yes or no). A Water meter readings,if available(last 2 years usage(gpd)): 2005 - 89,000 Sump pump(yes or no): AO 20U4 - , 0 0 Last date of occupancy: CupeeAA- CONIMERCIAL/INDUSTRIAL 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 Source of information: Was system pumped as part of the inspection(yes or no): .AoO If yes,volume pumped:_gallons-- How was quantity pumped determined?_ Reason for pumping: TT OF SYSTEM ,/Septic tank, ,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 �iaintcnance 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: Were sewage odors detected when arriving at the site(yes or no): no I'igc 7 of I I OFFICIAL INSPECTION FO101 —NOT FOR VOLUNTARV ASSLSSIIIENTS SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR111AT10N(continued) Property Address: 165 Warwick Way en ervi e Owncr: Step en ozzi Date of Inspcctlon: /a 7L BUILDING SMEII(locate on site plan) Depth below grade, 13* � Materials of construction:_cast iron ✓40 I'VC_other(explain): Distance from private water supply well or suction line: Conunents(on condition ofjuints,venting,evidence of Icakagc,etc.): •oKkc �9 g , SEPTIC TANK:`(locale on site plan) Depth below grade: /d " Material ofeonstruuion: ,/conc(ete nrelal fiberglass pol)edrylene _othcr(explain) _ — If tank is metal list age:_ Is age cunfuineJ b}'a Cert certificate) ificate of Compliance (}•es or nu)'. _(attach a cul)y of Dimensions: Jpo© Cellos Sludge depth: Distance from top of sludge to bul,unl of outlet Ice or bafllc: P Scum thickness: Distance Gom top of scull] to 101)of outlet Icc or bafllc: Distance Gom botiunr of scum to bottom of outlet Icc or bafllc: I tow were dimensions Jctcrnnincd: ,.( �llrau Coe g'r "�o Comments fun pumping rcconunurJativns, inlet and outlet ice or bafllc condition, structwal inlcgrity, liquid Ic�cls as related to oullci irvcn,evidence of leakage, ctc.): _Liic�ieall-y Sv,.,n �• anK n.cr o/S' -�-n �� •Cftw,�cl GREASE TRAV:� (Iveatc on site plan) Dcpth below grade:_ Material consUuction:_concrete l,lclal fberglass_pul)-ctln}•Icnc ollncr (captain):: — — -- Dimensions: Scum thickness: Distance from lop of scull, to tup of outlet (cc or bafllc: _ Distance from bottom of stunt to buttunt of uudet Ice or ball lc: Date of last pumping: Conunents(on pumping reeonunendations, inlet and uullet Icc ur bafllc cutldilik1:1, stluctmal inlcgrity, liquid levels as related to outlet invert,ct•idcllcc of Icakagc, cic.): 7 'Age 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSL:SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEICTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 165 Warwick Way Centerville Owner: Stephen I,0zzt Date of lospectloo: Y/5 5�;o6 TIGHT or HOLDING TANK: Nl ank Must be pwnped at tittle of inspection)(locate on site plan) Depth below grade: Material of construction:`_concrete_metal_fiberglass___rulyethylene othet(explaut): Dimensions: Capacity: Gallons Dcsign Flow: gallons/day Alarm present(yes or no): Alann level: Alann in working urdcr ()•cs or no). Date of last pumping: — Conuncnts(condition of alarm and float ssvitcltcs, ctc.): DISTRIBUTION BOX:It//�(if present must be opcncd)(locate on site plan) Depth of liquid level above outlet invert: Comments(note it-box is level and distribution tv oulicts equal, any evidence of solids carryover, any evidence of leakage into or out of box,tic.): PUh1P CIIAMBLR:�I�(lucatc on site plan) Pumps in%vorking ordcr(ycs or no)._ Alarms in working order(yes or no): Comments(note condition of pump chamber,lolidiliml of pumps and al1lmlenances, etc.): lgage 9 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 165 Warwick Way Centerville Owner:_ Stephen Lozzi Date of Inspection:_ t(`�-)f�e)6 SOIL ABSORPTION SYSTEM(SAS): °(locate on site plan,excavation not required) If SAS not located explain why: Type ✓leaching pits,number: leaching chambers,number: leaching galleries,number:_ leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): / / or/ c as afx 1/Ny�h,i,a waS n.y�-ei( LPat/, PtL # 42 wlis �(ny, G`� l�^�2 a� .f..nSPIC�z.. G-� i'�. M7 .4I��"t cs loft ,$•�+-,^ L�k 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY:414(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.): 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: 165 Warwick Way en ervi e Owner: Stephen Lozzi Date or Inspection: cab 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. - C26 b t' {'tOttSe Cc� a Pif- # A - a= 39 ` E-a . e/I' cif � d 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 165 Warwick Way Centerville Owner. Stephen Lozzi Date of Inspection: Id W f. SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 5 4-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) Accessed USGS database-explain: YouJ must describe how you established the high ground water elevation: G'S7ig- z j to ss l Cct°fd7.� P ' ✓c.J �[t /'ran 1it a p' 11 tit o COMMONWEALTH OF IdMSACHUSETTS i JUN 91 200 EXECUTIZTE OFFICE Olr ENVIRONMENTAL AFFAIRS v DEPARTMENT OF Et MONMENTAL PJRO dMON1 kDH�EpT� ONE WINTER STREET, BOSTON MA 02108 (617)292-imm 'T'RU'Ut COXE lietsets�ey MtGEO PAUL CEI.LUCCI a:.M)]I.13TRUHS C:awrnor Ccdmr�wsiotur sUWURFACE UWAGE OSSPOSAL(SYSTEM INSPECTION F0I1M PART A CE11 INWAT1011 Pnipsrty Add►wa; S w ray Mena of Owrnr, 0A r , J f Cc✓�!�I 1 Aftese of Orwies10111111118 of vg&t�f.. 1 arirt a bEt i ,prrrarrane m s 15.340 of a(310 CMR 15.0001 Cis Iwo ry Nawto: N •�'[��,5 11 0,g AdAres.: 4sfa�Aane Ntrtsom.. nE I c4i"that I have personally inspected the sewage disposal system at this address and that the'information roportad ibdaw is i ire, a*txrr+r+ta and complete as of the time of Inspection. The inspection was performed grad on my tt*wno and experience In the prePnr lunl:tion and maintenance of on-she sewage disposiul systems. The system: Passes CondidonsNy Passes __.. Needs Further EvaluRPOn By ffio local Approving Authority Faft agesesr°s>ttprreawr` -d�����L���, IDsM: The System Inspector shales submit a ac py of this inspection report to the Approving Authority iSoard of Heal$or CEP)with,in th�ii ty ili01 da!fs of corriplsting thip inspection, if the syett m is a shared system or has a design igow of 10,000 gPd or S►esiter,the Inspector ana:tti,�syttarn r�wnw shell submit the report to the appropr)e:e regional*}flea of the Department of Envlronrnental Protection. The original shouird be a rnt to 8!te system owner and copies sent to the dryer, if apoicsbia,and the approving auryto ty.. ilOQ1'BE AND COMMENTS Wised 9/2/9e Pw of11 0"At.d On awwied r.r„ r SUBSURFACE SEWAGE DWOM&YSTEM NSPECTION FORM 'ART A COtIV4CATWN(ow lnuaill .rliew V /6�GUarrl'cr+��� owner: �'f"l•at.v/'� -� Dow of Yna'sersn: S � N/pecT10N SUMMARY: Cbaok A, R C, or D A. SYSIM PASM: _ I have not found any Informallon which indicates that any of the faltlars conditions described In 310 CMR 16.303 sjold. Any Iralum criteria not evaluated ate indls:sted below. CO�IiMBfT`t<: B. SYSTEM CONDITIONALLY PASSI.V: One or more system components as described In the "Conditlonal puss" section need to be replaced or tspaired. rhrs a rstern,upon completion of the replacement or repair,as approved by the,hoard of Wealth, will pass. Ind lams yea, no, of rot determined M N.or NO). Describe basis ermination In all instances. If"tot determined",sxpieln lift not:. The septic tank is n loll, urge"the owner rator has provided the system inspector with a can al a Ca tific-att,a! Compl anoe (atU hod)Indicating Mat tank was inataiisd within twenty (20)yeas prior to the date of the nspiwt on; or Me septic tank, whirther or not ,bs cracked,structurt4y unsound, shows substantial infiltration or sxlydt,stiay, et t•snk hAun is imrrrirart. The av well peas Inspection if Me existing septic tank is replaced with a compgpingi s,ptic tank as approved by the Bo wd Sewage up or Ilreakout at high static water level observed in the distribution box Is due,to broken err cobs fueled pig*ts) or duo t broke, settled or uneven distribution box. This system will pass inspection If(with approval of th i Board of Ir►oken pipela)are replaced obstruction is removed aRistributlan box Is lwalNd of replaced The system requirli pumping more than four times a Vow due to broken or obstructed pi 91. The sys+:ent M NI pass Inspection if(with avroval of the Board of Wealth): broken pipets)are replaced obat►uclion Is removed vised 9/2/98 low 2of11 SWISSURFACE SEWAGE DISPOSAL SYSTEM N KCT1ON FORMA PART A CI91TiFICATIDN lea+tihkssdl Poapssily,Address: I fj f'4)rG�cay Doe C. FURTHER EVALUATION E POWWOW SY THE BOARD OF HEALTH. �.� Conditions exist whkh require r'urther evaluation by the Board of Health in order to datermine if the system is faYirip to lIv*tort Ito pubIN heal safety and the environmeitet. too SYSTEM WILL P"S UNLIM BOARD OF HEALTH DIEI WAIINES ill ACCORDANIX WMH 310 CUR 1!i 21111b)'T%AT'THiE 8t►S1;Elt IB NOT FL"WT�1 M IN A fi kWER 1ABRB��H VML PROTECT THE PtlBIAC HEALTH AND"FM THE SUVNIOIAlIi,MIT: Casspool or privy is within 50 fact of surface water Ceee/toel or privy Is within 50 4set at•bordering vegetated wetland or a arsh. t3 SYSTEM W LL FAIL UNLESS T1�E BOARD Oi MTN(AND PUBUC WATER SUPPLIER.IF AWY1 DETERMINES Tlhi►T ITIE S`fS!itlrl M IPdO IN A MANNER",'RAT TW PUBLIC HEALTH AND SAFETY AND THE EMVMONMENT: The system has a s4"Vc and soil absorption system(US)and the SAS is within 100 foot of a surrface winter supl)llr or trlbutaly to a surface supply. The system has a a e tank and sell sbeorption system and the SAS is within a tone I of a public water supp y well. The system has a rtic tank and sail sbsorption system snd the SAS is wktdn 50 hat of a private watN'rill y wen. The system has septic tank and soil absorption eyetem and the SAS is fees than 100 feet but 50 foot or war, tram c pNvats weber y ivd1, unless a well water analysis for coliform bacteria and volatile orianic compounfs inc cares this!:the wall fa free ern pelt lion from tiset fediiNty and the prceenc•of ammonia nitrogen and nitrake nitrogen Is eclus to or Anse than 6 Method used to determine distance _(approximation not valid)• 31- OTHER re-ii,dsed 9/2/98 Psse3of11 Sl1BSUMACE SEWAGE OIAl0"L STITS11111 NIISMTWN FORM PART A CU I FWATM fasarMrarals Pratliarty /6 S GC�o/'l�+tC.� (1.7C y 0. SYSTM FAKS: 'tau,duet Ondicaas aitfta"YOO,or"No" to each of the following: I have detwmined that one or aws of the following failure conditions exist as described in 310 CMR 16.203, The bans i for ithla OwmInation is fderrdfled below. The Board of Mealth should be contacted to determine what will be necessary to cnrruct tt,e isiiure. yes No Backup of sewage ileto facgety or system component due to an overloaded or el SAS or cesepool. Discharge or pondirq of ellfluent to the surface of the ground or surface w e due to an overloaded or,doggn i SAS Ibr Cesspool. Static Aquld level in the distribution boat above outlet Inv us to an overloaded or clogged SAS or cesspool. Liquid depth in*eesitool n less than t3"below or available volume is Less than 1/2 day!{ow. T Requlrsd purr+ping mine than 4 times I last year fW due to clogged or obstructed pipe(s). Nunsber of*"at pulleped--- Any ® portion of the SuH Abe on System,tesspo*i of pri%ny is below the high groundwater elevation. Any Conlon of a cos col or privy Is within 100 feet of a surface water supply or tributary to a surface"later luppiy, r Any portion of lipool air privy Is within a Zone l of a public wail. Any ports of a Cssupool or privy Is within 50 feet of a private water supply well. An an of s oasnpool or privy Is lees-than 100 feet bu greater then 50 feet from a private water supply v,oil with nc ptt�bla water qu.Idty analysis. if the wail has yted to be acceptable,attach copy of well router r,laly.lis for ooWwm bacteria,vo!adle organic colttpound onis nitrogen and nitrate nitrogen. E. LAMM Sv PAU: You roust lo"icate 41tha "Yes" or"No" to sec of the folowing: The fedowing crkwte apply to sr tents In addition to the oritata above: The system sarvea a ficiAty a design flow of 10,000 gpd or greater(Large System)and the system is a significant .threat to iwbNe heah/74"V the a �onment because on®ar more of the following conditions exist: Yes No s within 400 last of a surface drinklno water aippiy la within 200 foot of a tributary to a surface ddrvking water supply is located M a nitrogen sensitive ores(Interim WaMeed Protection Area-1WPAI or a mapped toms II of a loutlic y won)The irorner ofch system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult t" *cal re;Icnel o"oe of the iDeparlor"Cont for further bhfel"ordon. re'v i s ed 9/2/9 6 PM=e a of 11 Y� tltf®6UIWACE SEWAGE DISVOM SrtlTM tfi✓ePECTON R0 PART S CHEMLOT ice•+,A �w(T,�J" a)" O: ��'�" Ctwock If the following hove been dons:Ycu must Indicate either "Yes"or"No"as to each of the following: ep No puartping Information ass provided by the owner, ocoupsrtt,or bard of Health. _ None of the syston components hwo been pumped for at Iaest two weeks and the systsrn has been reaAmInlj n rmid flow rates during that pored. largo volumes of water have not Iman introduced Into the system recently at m path e+f thfsa inspection. As built pllans have b+reMt obtained and examined. Note if thoby we not available with N/A. // The fooiilty at dwol8a+g woo Inspected for signs of**wage brick-up. 1[ The systom does not rpeelv*non•sanitery or industrial waste low. The gibe was in lIlWhKi for signs of bfaak*W. AN system aompononte, oxolwdng the Soil Absorption Systems,have been located on the site. The septic tank manhclas were uncovered,opened, and the Interior of the septic tank was inspected for c:cmell.tii;n of boNles at tool, material of cenestruction,dimensions,depth of liquid,depth of aludge,depth of scum. The aft and location of the Soil Absorption System on the sit*has been detormined based on: _ Jv� Existing Information. "For exompie,Man at S.O.N. y Determined In the lid (if any of the failure criteria related to Part C Is at issue,approximation of distance is uno soe,ptokls) 11 i,202Ig)(b)1 _ The facility owner Iwo$occupants,If different from owner).tore provided with information on the proper msinn i.nsnc;a cof Subturfsos Disposal 3yotems. revised 9/2/98 per 5orti sU"URFACE UWAOE DISPOSAL s fsTDA NSPECT10N FORM PART C SYSTEM NFORM'ATION o.a.aA N l4 OrJ PLOW coNDfnONs Does .p.d.lbodman. Nurivim of bodroomss`a*qfgnl:_.Z Number of bodrooms(actualLff ToW DESM ftw W,_ Nunsber of ourrm rooider".Oeebaga grMtder"or no): i�G, Laundry(separate system) !yes or no9:,!' 14 yes,soparsto Inapaetion requlrsd Lawnd►y system Aspeved fd�s or no) '�` n Seasonal use(yes 0 nol: g g Water motor readin s,If as s�Wble(lost two year's usage I pd): dZ sump Pump IV"at no Lon:date of oosuponcy Typ(I of I Itablisbm ent: >,eslf/s flaw: and I suet!on 16.2031 (teal/of design Aow Orarae trap pro-of .(yes at no),_,. ---- ----- ktduWW Waste holding Tank present: lye ns1,_ Soft-sanitary waste d echergad to tie T E system:(yes or no)— Wassr meter readings,if aysn@Mo: Last date of oacupancy:Z_ .- OTWO:IDescrlba) ast date of occup y_ --.- ONOWAL N>FOI{MATWNAA,,,, ►UMIIINO RlCOlb@ and Infra"ation: Y V1 L r Asoumm7 systam pump ea part of insrectlon:(yes or nol if yea.voluo a pumped: „__gaNans Romeon for pumping: (TOTEM sopdc tankldfeld SFWboll absorption system =(mole Cesspool .,�.,. Overflew cesspool ...__... Prlvy shared system?yes or no) (if gyres.attsob previous Inspaction records,If any} I/A Technology+oft, Attach colt'of up to data operation and rtrektteruarlcs contract Tight Tarok Copy of D;E►Appraval O*Wr r� A►N GXVM'M AOE of an vang orents, lots Inguilad Of known)and source of informatktn: Sam@@ adore detected when arriving at the site:(yes or no)�d revised `9/2/9.8 Pop Cat 11 Itf,MURFACE SEWAGE DI POSAI SYSTEM SMSPECTION FORM FART C SYISTb71 MMoD11�AATIDN tsenMrMndi Pls e*Adtlreso- Deft,of bwqpMi.+Iso: /asrd VJL I llo.Kesel: Moomts an site plan) Depth below g„de:922� r MrAwist of construction:`east iron 40 PVC other(explain) Distance Noeq plivote ureter supply Weil Sr suction line --_� Diameter Carnrnerrts:Io,4ft of joints,verttng: "done*of leakage,etc.) SffllnC TANK• (leaste on/its pion) Depth below tirade:/// Mattid l of construction:4eonerate_metal_Pibergless _Polyethylene-, .0thertexplain) it tarwc is metal,list ape,,,,_ to ego eonflrmed by Certificate of Compliance__(Yss/Nal ao ' Mmelens: Skadlp depth: y Distance from top of sWPP to bottom ad'outlet two or baffle: Sourn thicknos: 4(/ Distance free top of acum to top of outl(tt too or bafffe:rS Distance from bottom of scum to bettor, of outlet tee or s: tow dimensions Were determined:41 .r Cormrtttnts: (reeornmendoMon for pumping. condition of inlet and outlet toss or beffiss.deisrth o�llquid level in resat gn to outlet invert,strut ue ii intrpe.ty, p s ryes of,isekego. e.) fi,A� ,l,e..c Q aa�, ar � �� 41 LGQ R.as ii1 br: . OIilM"o . 06"te on ohs poeal Daptie bebur wedo:__. Material of oemetruetion.—concrete—maw_F"Hwens P yfens,_„iothadexplaln) Dbman,fons. Sam,thickness: Dia'Afte from top of mum to top of"Alot us Mae: Disttr000 from bottom of scum to bottom of at tee or beffie: Detest lost pumping: Ceamemsets: ireeonmsrrdation for pun pin nftion of Inlet end outlet tees or baffles.depth of liquid level In rotation to outlet invert,strjeuur,,I kwegr ty x . Wdoe of Isekegs,oft.) revised 9/2/98 of11 c' OlMURFACE SEWAGE DISPOSAL SYSTEM PAPECTHM FO1#iln PAW C STS M NPO MATMI toorrdaarae 19etco TIOOft 011 HOLDNO TANK. (Tow,(rrw(st be pumped prior to.or at time of,Waq ctlon} N"W"on sta phn) Depth below Orsdo:— M awlel of cone allon: concvete_..metal_F}berOlass_Fel were—�other(expie}n} m ono}ens: capw t1►:__Ovens D"14 n f w:_Oollons/dsty Alarm present— Alarm level: Alarm in woMi,. ardor:Yes No_ Date of previous pumlNrv:_. Cernnrents: (coem tion of hOM too, con f afwm and 4last*w t h*s,etc.) DkiTINIR 1011 BOX— Ometa on era pion} `.Z*th of iip(td level abe"outlat}nvsm: commute: (note If level and diem s e,ue},ov-Wenc*of son,ep"Y ' pids a of NakaOs into or out of box,ate.} o Poeni s on olte pion? 'ut"In rbor"order:(Yes or Nab„,,,._ �„�,.✓" Alsm-m in work"order tYes or No!_._ Cornan d : (note condition of pump ettarrtber.rend den s WW appurtanances,eta} revised 9/2/98 VUBSU IFACE S MAOE DISPOSAL 8ISTEM Dt6PECTIOIN FORM PART C SYSTM VWO MATMI(,ewd uadl caw ROTA.„AMO1lMe01lI.YSTfAA{RASAi YNceota on aka p6�n,If possible:excav tian not raquired.location may be apprc-ximatad by non-intrusive mathode) d ni Wated,wolain: Typo: lasci plta,news w.42 laoohbeg chernbera,nuenba:___ leoWWwg pelivii s•noxoabaro— Naahing agrchae,rwarsbor,lettrth: laeehbtg 9".nundnr,dWwalons: cvwftw a.aagaol,number.___ Ahernative ayatam: _ Memo of Tochnoli Colnmat�te: (noW condition of s ' elrw of hydraull9 foilurs,(oval pf Pon no, dom sob, cimi itlon of v at tion,otc.) 94 Ott- CESSPOOLS._ Yocate an o@to plan) 'Nurnbor and eonflperratNn:,,�,,�_®ate "-9spth-too of hi to Wet lnvwt._.�_� oath of si Nyw: Depth of scum loyor: Dwwwiww of easapool: Mailargtle of eonstruetlon:,_„_,,, trtWe+stion of groemdwai inflow leeaapool rowa<Ila pet red as pert of Inspoetior)�� ca mtwr+es: (note card"Un 0 soil. of hydraulic failure,level of ponding, condition of va"tion, otc.i PIAIAI'I's�,,, (NNW*an she®tart Matudato of carpnruotlon: Dimensions: Owes of aelids: Cornr:tants: (note condition of soil,aigns ydroulle frAure.loyal of pond",cond ate.) an of vegetation, revised 9/2/98 Psgtfof11 r r _ :SUSSUIIFACE SEWAM DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM NOPORMATIOEI IOINOWsOM lG -4'CJJarw1 We (,tic- , s: l.a.�rtr.-�- 1 CON" DMI GIC dwapaalbns '�/8�t SOM"OF WWAM OIMFOM STSTIM: Inak da Us to at I"n two pannonant rahranea landmarks or benchmarks locate all weds wltMn 100'Musu where public water supply Cocoon into house) U I Ilk 3� revised 9/2/98 hr10of11 i USSURFACE SEWAGE OISPOSAL SYS I M 90PECTM FORM PART C sysT>Esl�PoaMAraw tooneir+edf P"pr"Addhom: 1 5-0ar-dick1J-h- Or110 o c5{— �Q.d r'0.�t' 1 NRCIQ Report — Sell Tppa_ _ T4001 depth to proundwotar__ - USGS owe webe t.visited Observation welt chocked Groundwater depth; &Wow__ Modesto --D*"- SITE EXAM $lope Swhce waver Check Celar Shallow woos Estimated Depth to Groundwater J2 hilyt Pleaet Indicate all the methods used to 00tomdoo High Groundwater Elevation: Obtained from Design Plana on racnrd Observed$ae(Abuttlnq property, Nbsorvation hole,basement sump etc.) Determined from local conditions Checked with local Sowd of health Chocked PEIVIA Maps Chocked pumping records Chocked local excsvators,Hwteloru Used USGS Dow Describe hdw you established the High C roundweter Elevation. (So be complieted) revised 9/2/9 8 Pop 11 of 11 r TOWN OF BARNSTABLE , LOCATION ( G�� 'I SEWAGE # VILfAGE �� W `�'E ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �G LEACHING FACILITY: (type) �� (size) NO.OF BEDROOMS BUILDER OR OWNER &Sd- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: ° Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (lf any wells exist ' on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Mfi l�je.P" , ARQ ►/ �nv,kw, gC�� �� , ; .. �. _�,,�.� ,. , ,.. `. � � �, - �� S � � c f �c � ` LOC L1,T LO�t-u��� 3&C.4 E PERMIT kl O. VILLAGE - - - - - - - --IW§TALLER•5 -U NlE A DRESS - -BUI DER 5- .� 1��%,,9�E ADDRF_ 5 - - -- ----_DL.lkTE . PER-W77T 155UED =_-s _Q°-�../ - D-ATE COMPLIAMCE. ISSUED : _ L., r / �y� _ �/ �� � �d I No.-••---.��............' Finc ?.. ......... THE COMMONWEALTH OF MASSACHUSETTS /� BOARD OF VE LTH . ...........OF... ....................................-- Apli iration -fur Uiiipuuttl Works Towitrurtion Vrrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ------------•--•--•---- - --- --•----•---••----•-------'•-••.o--....----....:.ve �f o atio Tess or I of o. wner _ Address Installer Address „^ Q Type of Building Size Lot...../s./• ...Sq. feet U Dwelling—No. of Bedrooms...--.-.--- .....Expansion Attic ( ) Garbage Grinder ( ) aq Other—Type of Building ---------------------------- No. of persons_--------------.----------- Showers ( ) — Cafeteria ( ) Q' Other 6 ores ------------------------------ W Design Flow------------S.............................gallons per person per day. Total daily flow---------2MO-------------------------gallons. WSeptic Tank—Liquid capacit/-:"..gallons Length---------------- Width_.............. Diameter................ Depth....--..-------- x Disposal Trench—No. .................... Wid i. .-.-----.-.... .. Total Len -l.................... Total leaching area---3-0--'L .....sq. ft. Seepage Pit No------------------/Pikki � b ------ .-)Total leach in area...-- ---------- ft. Z Other Distribution box ( ) " Dosing tank ( ) ��� — G— J" aPercolation Test Results Performed by-------- --------------------------------------------------------....... Date------------------------------------.... Test Pit No. 1----------------minutes per inch Depth of Test Pit--------.-.-..-----. Depth to ground water.....-----------------. �14 Test Pit No. 2................minutes per inch Depth of Test Pit..------............ Depth to ground water-----.-..--.--..-------. a ----------•---.... � ------------ Description of Soil ------•--- ` �.-- `�'- I x - W U Nature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------------------------. •-------------------••-•----------.-----•----- ------ -•--------------------------------------------- --------------------------------------------------------------------------------------------..-... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the bo d of health. e 9< 4 igned. ..- !t� -- --- ------ .... Y/ �C Date Application Approved By..�..... �_�.! ..... Date Application Disapproved for the following reasons---------------------------- ----------•--------------------•---------...........-•-•-----•--'-------------•---. -•--••----•-------------•--------•----•----------------------•-------------------•--•----------------•-•-I----------------------------------------------------------------------------------------------- ate Permit No......................................................... Issued.- - -----•... Date ------------------------------- ------------------------------- ---------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OV`4' .I........ O F....(-�� .......................... Aplrliratinn -for' Bhivasttl Works Tomitrnrtion Vrrniit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .................................... _-•-•-•......•••-- Loc tion-Address _ 141q C�i{ PC (� tTQ I11�fJ•v / r Lo f -------------------------------•----•---......------------------•---•----......- ( � L / p pwner` / ` ,�o Address ...... Sq. � Installer Address •� U Type of Building Size Lot...... feet /:..r- - �-- �-, Dwelling—No. of Bedrooms------------3__--.._.-_----.----.--------Expansion Attic ( ) Garbage Grinder ( ) Other—Type 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 7 -gallons Length---------------- Width--------........ Diameter_---- .......... Depth.....-.._...--- x Disposal Trench—No..................... Widt t_ __-......_-_.. - Total Lengt _.--_-.--.------.-_ Total leaching area-.--?!?1 1......sq. ft. Seepage Pit No------ -----------/ +fir d k'b Gtteirz - otal leachivarea 7 sq. ft. Other Distribution box ( ) Dosing tankQ aPercolation Test Results Performed bY.......................................................................... Date....------------------------------------ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water....-.---.-..-----..---. fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-.------_---.-..-.-..-. R+ -------------------------------------------------- ------------------- ---------- Descri tion of Soil :..... -�`'� r..� i Q r S Wr.. _ --- -- ._ v - x --- ------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- ---------- 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be/een��issued by the board of health. Xgned-- -(..!j Date Application Approved BY Date Application Disapproved for the following reasons:----•----------------------- --•--------------•---------------------------------..---•----------------..------- ....................•-----------------.........-----------------•----------------•-••--------•-----•••-••.......----------•-•-----...................------......._....-----------....------------..-•--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :..!..ci '^............OF.....fil... .......................................................... Q.,rrtif irttte of 0.11mlifiattre THIS IS TO CER7 IFY, T at the Indivi}.al Sewage Disposal System constructed ( or Repaired ( ) by ................ � -•-..............' � --------------------------------------------------------------------------------••--------------- instayer -----.------.- --'�-- J ,�a 1.� lam^' ------------ at has been installed in accordance with the provisions of : 'tiQ.XI of The State Sanitary C as described in t� application for Disposal Works Construction Permit No. ?J _-.���s�,,-__......_.. dated.-.. THE ISSUANCE OF THIS CE-RTIFECATE SHALE. NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................................---------__------------------_---------- Inspector.................................................................................... a. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L7.j- � _u" �/ OF.................... .......................................................... FEE-•-..................... i� n�ttl ork� Cloniitrnrtio iV rrmit ------ �/� ec./� ��L.,� Permission is hereby granted..................:!<! -�__.__.`. to Construct ( �o Re qir�( an Indiyid,•tial Sewa e Dis a S stem/� at No----------------------�.�-#.. (J-'t1'C./.c.�I p y Street as shown on the application for Disposal Works Construction Pe No.... mil.. , ed.......................................... C..................Board of Health / + DATE----f ' `.. r FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i 1f ni. F.Y 'e wd F Jv„ `�. iG.....„'. � .'�w'��•...,, / '�O � �.�/� w'"� d,�'�Y A�l :;a �y� 1•! ti ��1 >z F���� 'r` _ '.,•. ,wry v..'^... � � 1�� �`^w zi��`� �l 17All IQ AV 9 r 2 igr � �T�/rC•r1 `':Z. � {. �: � '' 4Pry Y w C .Co 7" �fi� � r A* "�' s��!��T!®�/' C•�iV'.�'" .8'✓/G G.E .�1��.�'. — �c�C�o .Z`iyT/Cr �'7"i�'�+�=��� �^' �+w�� s •`•S +u " .oGA.C--' ✓E ° ! �NL°L�EB� CENT/FY TNFiT Tf/E OPIA-1 O.t/ rW/S -LiWAt/ 7 'iCaGOii/D q�S ssdOWA✓ H&. 'BOA✓ A.IJD 71"o 7- +� e w .—O-W CO.L�C�,OA�! TO Ti�Fr ZO.C//.t1Gr �Q� a ,L.�ialc� of 7-"C- TnW.v oF- 46W�'.ys7;14S4cE `, c? ARNE �� OJACA q 2048 civic. 2,vGia/d1PC-AWs 5g,i � '4 L•�2.V D S(J,C-�V6 YO BS /f/ZS/I� � a"'` ��, ,C?�tJT� 6A^- 2MOCJT�✓, ML�55. a.gTE J . - . .. N �s 4 0 17 ILL— I I:. , I. ..l• 'I" it �� 7... : Y ov r al ' K h I K°Ey I . ... _ot.,�.,- >: s�oxM`i. x..•,'�Y-.�-:,_,{,,,:;s¢.,w' ,. - :, ,,.,. a,j :''��� xs�'=•. r"-� - w� r 't•�-�.��,,,vi'.�,�' .:"5.> i , { i ram• - r ,. `a«, "' "...:- - .:ems. �,,�,,� C ''��. �� �z•%�.�'-�ry �� �2`„� '` t : ..... t' rn ry. a'. iwsn- �"-.1�...r:�a.:' -.. .•.',rty. ,^..,^'- ;. e� e ti, *IBI' h >tpe�"'-, .:eg 9 at .. ...,. ..... : ��.,.y._: ..,...,x.:. ..:.. � .,,. •..--r+r• '.A'' i-�' i)1 ��. ^•R:K _ .�/, ref �.. .. - I 77 '[ F. of AQ_ 1 1 I. .. ,.. � t_ �r- t` :�ll �. )_I:1_ ila-p•£O7'—_.I..�Y �'j 5J'::S I � ,R�, ' K L Bruce Devlin .Design® _. - 3 _.. .. . 1 I. '-C6�._lF�-��6C cv`„c�1 m. ' 774.238A77' t ---- , i - — -- : -_ — �' a••e,.:0"7 _ .. (. 'S'�' }/may , r f I j. - ._.._..t.. i , - I t- 1 fi > I 1 y�. a it�. I ,�: `.jl� 'I-� it 1' I I t_!; 1;' { r I• j ,... .- ._ '� a 1 A � �. -"f �' •,rT; .I ti'Ir, I t D ,. �{' .a .I .. '- � .. _ .(�-_''�_. .! : 1 ..-_. ..:.. 1�:•::. � I;1 1 r,^•;::. ,µ.IqI 'j�t .. .`( �� i I ,•.. I ,I;: �I. L� i, r rl 3- s�'� -'('::fit•.. S'',' ;, 'ip, } ... . . .-:.:,:..,..._. ....... .... . ;i-: � �-• is r . : •. ... .It.::sl ' .,� � : � l :}. ia, I �1 � '.'cci it pp F� - .. .. I� � r I ,4. : Alt I' ' .'� "� .1_�,,-�-,.,}y�,' ,,.aE$ ..._ ,_ram- '�.. ryy� -4 1 'S4'r•. �1, I.',: � .. _•N i ,,. .. ( 1� -�,� �' - I'�r ,I } rL N' .1�' `7 Ili... 1 _ .` � r ,.28 i:• ";j.. Mt ail_i�:r. Au I(. L ti ..: I b I -'I —'i e`er- OFAP K! I. i I .t:... •w g.gn.. ,. ...6,3 _ M1 y,ql I ,eR _ " 63'trL'.:.9:6-lo` t;6'•I ,. .. - cqd: i �; i I �L;•. . r .. .. I - fl -- -_— rue e YDev11 n 7742388.0773 r , : it Il •' AWC Guide to Wood Construction in Eieh W/irdAreas,:110 nolt~Zone � � � AWC Guide to Wood Cipme,. bn in High WoPdAreas:110 mph Wind Zone ' 1 ¢Wa'rrl'rt //0 nl h}41nd Zorre eClChSt ff)1'L'OIII'nhaIICe(760 C98SS3013LI): . .APPLICANT TO COMPLETE E SUHHI4'N+YFI"P,E7iMIi AYLTCA�tON ,AWCCrr,7(/e f(t.YDad Cnr,Y , . _ Massachtisetts Ch Massa¢hne(tty Checklist for Compliance(Teo cant sd n zI.I)a ist f qni 1 peonititssgl2,.lj' • t nctio/1 in High trLndAreav,1/OJ+ri+k,W/r/Znne - - . IVlgssa f3set 4, eu aide w Wuod(,ottr.S, '. _..�.:.b..-. :` :' . .. �o Cntt3330.t E1•{lf ... .. From AWCCi .. Load, 9.ugae,G" n cGona a' slssaclwgetts CfiW.tlist for�Um.2LlBncgrr .= L b. W d�6twndutletl Urt�e�'WIBalhemaMe11 oti[1.8"mod Eelnatplkd kGows OamPtvn�. pto!i,�VOBdbaa^9 Ps ___ a_..He � __ L.pandeSt Ap lad N�Mll_g8l alda paraDeYlo 6tud9, Pelmld Yu ' dyi Ia asl hwbphtil ' .....:........_...;1t0_IPDh i? lye HeedarSF n>: .__"'__"•_._...__:_�y3 but ' ,. er edaU a ' Njbk"Salm_ -(rcom • ..3••-.lgrpt .:i h1-511 �/ 'I& On single 6(o!towst1d� Pena eAaO bed ed ard be min m t6a etidg. memh ofth N 0.........,.............--._. ....._-.._...- 514 P.Iabs n6"`:-.„...:._____...._r•-•.._._ de.. _ .1! aD Isla• - wmtl:SFeed(3-sePr us ...._......_._. - _ .. 6Y soma_._... (Ta <glper pe I he eRobbed to,tlf `memo Nil I double w,aa E(vas"ra'(.'eI TY ........................... fn: a'.':. dH�did !.Penings(iamrd laBeat PPenlnp but UiaC.atiopeNn/Y_Y corVlv!�at)" =^.Tien s12' y N. tppllot.aarlW� mb ZI,upper eltal}Iment?.., Dene,,ahae . .°32ltn ----"'-'(rabl.e) (SP�a• 37,. - °Ist . ,.z aPP4CABILITY e,ao'("job e%ceade aln/2 zbpe,shall berAnsbafea astorY).: Sad - 'tlak 6Pan?•••.: •-•_.-'-•-•__._._._ -__(Tabl99 .. }_ fin• .�i �d6td'. .: ,per,�t eCP9H ftautle mw of 6d�l� _ NYmbarbBILITax( f •.. ,Isla SPene-.._.._.--.__...,__._._�_.._.... � fir' �6 ti3YNa8100 N..(FlR 2)"_:_'-__._:_ d&e $.538' rro:o(a)uda)-._-- ^-....-.-..(Tatda g} p m elpht sLlAe. .. Roo' (ftg 2}•••-..._....._......• E;BP -- aB X. toRWWUplla and Sheer Slmblbnaously' r F Moen Rool H818ht..:..................:......-....-......:........._-. .._..._.......:......__.._. '• .Sell - olmenelen.W' _ ............._....._._..,................-....,, _............-._ ,S.a e:. ilelum 9a. _. a Building Wiem.•w. Nam of H4lgp;_afTalleat Opening' ....aPe4- . _ � end lolwr Building LenBR L........... . .............. a}._-...... _�.ae'e- -� - '. S• �BTYDa_+._._..J._._.__......_-(h �-----,_...,,.,..:_.•,,:::--d-" .• .. ' v. FbtaPjdel ne0 spa 'be�.s I Vpltloel ttn0 Horlrtgl ( Panel AtlHdaned / e eggared uadin ASPact Rabd . -•_lFig4}.46M.(drJR at 3 bldtee ,- B g -al of Tallest Opening "^"""""' Sbae{ilp-.. rrofP'atfl ) Nominal Hale / �•n nglli.Wbl. ' LNG CONNELTIONS (TnNe 2)....-r`•-- .___..._._..-_ �ICWirIeeHOri{ne.of lBd Gammon!lPee .. .. , t.]F,itAM .m Ramiey wnn.edons-......,._..... pe Fab{{elgh!$healldnB-._._.--_-(ra ) c,,,arelaomvnanae,:n r - 2,.FOUNOATt7N ...r....._-......_..-...-_ , _.. - Fou'DAnWalls 9-Iing reoulramanl!olNeg CI4 Wht - _ I}`� _ __ - ._ jpa�nyDp.Bid OhuensWn 4•''�'1maIIIM fa (�aI),n elOhP afyt0Pa+in�.. 4 ..........:......................................... ,..N� _� -_ - _ _ Il watt opruifne>'8)8 •::.. n+e ..._._._ _ .W.Y__-_: CMcrot.Masonry.:................_.._.__ - 011 grrota 4 rf lees --• lbdt' .._.._�'_In. �•�. j SpaNng---- n 2:2 ANCHORAGE TO F04NOA'1011 MachnnloaLAncnom as en nitemet(ve In cona{pta�r4:-t., / i Po� -_ ' -�.L-t1 ,�� .Gip 6d WnPrtdlt naAB(,reble 11) ^..- � ;• a(nil.Rf 1 I •I s/''Anchor Golfs imbe`dded'9t5f8'PrvPdam.Y.......__(Table 4)_._...-._:.-.._._-.._ ,��yy'I.So":�12• �'� r �"'8-- WeII WB(I opening as-MaetBny )•--- i-^•• I :XSF!-®•! g ocueaW4a0oeeVYaededlL - Oon or solo-g era!__......_....._-....... y Ibl r - BoIISPadnBlyhend(olnt of plate_...__•_.--..___rPl°y?'.-'-_.-'._......_.- �InzT _]L- yd( -_-. - --• '•- s S96 AttdWa eheetltingb _..__v:'--'-'-'--• .M1zis Will.._._.__......_..Fig�._-;..._--._ y -Y;j��:,or__l )� y --� souEmbedmenl•+c .._•.....___(FlB s}.___.._......_._-__ .i$xa'x y." -1 I e ❑eblf Boll Embedmtnt-mason?..'Y._.- .....,__._._-._._.._. --•••� , 1 ._a-.....-..._.._._..._._..(Flea}...._...._. 6.1 , - V dnt Plate Washer........................ 9�. - or us ) ._.-. J aOQ]'t, ramM9 mambarepero Otter:load2.._.-...:.-. •gRa ueeA ;;fiM m,;sae BB. !i. . ter 55)._.._`... u{9�...-"lrg' bamdbr4f w @ r h ]A FLOORS •-..n`a eherJcea....__.:.....;_.._.......liar seo CMR CinaB aa12-�mang ----- - _ member avb:. - ate_. �� Tteiae or l,efetarine, etla9dne'ala®WdILs ) C« b). Foot tmmiag ...(Flg,6).:_.w•;_-._._._..- _ . imam FloordPanln9 01me o -.....:____.:...._.... ......_...-.. .. . mm� / Max �! Floor ovening6;laee Ipan r rmm Fxenor wall(?B e1..............:;-._. r.•. ' . .� . crane!and flodmntal Nelitrg hf Panel 1116adim Full Halghl Wall Studs et„ ft yd.' �L.._' _ ._ - ^-'- ... a :. ..�_ 1 . (T9 W 12 Ma%imam FloorJois[6etbada (Fla --^`• -- ": _ ....... .....-......._...__ > Supporting Loadbes%In9'Walll or SheeM*0............ ( DT)- � L.ataral_-.«__.-•_--_......_._:..__(r ,t2)...-•-r- ••�7.7 L` Pa . ft'�D/' .+.:._....��Pg _ V • Maximum CynGleveiod:f7 or Johle ---- 2 S�ppoNriB L.aedbeadng waltr or }._..-........._-..._._.......:....._... _, aSUapC ecuon6,nrwgPr ass nd used ParpeBa,�11=:(reblP`ta). - Its....._.__._.._. .....-......FIg 9).__,...-.__-...... p>3Ke'Y7.'4(biker._-__.._.:_.-_._......_....:__(Pule 20.m-.-:! ..�Ptseloeltar of2•or L/2 ...__.__. S ss...._._:...:._.�.____. I Flnar Bmdn9 at ErMWa _._......--1va+76o CldR pnaPta! ) _y�dlri �C �� .� dr Ranar cdi;SkFgpns e(Nol)-LoadbP.png weVe : I �tu.°�m�At Floor Sheamin9'TYlla.......-._........-_._-._-..._ S5e Floor Sneethln9 TNcknass...-.....-_.......____._........._,_IP>790 CNIR dGt1a )"-'-I!bad9e/�bl p :^+ diaasn::. :.:'i•_t'Yapd ^ ._ '-- _..__._-.. .. Floor Sheathing Festening...:...........:-_...__._.:..-. - '__ 66 9 . ' _ - - 4.1 WnlLS ,�. aut(s10' ..9' M _ .. _ - Root Sha:fHdne TYpa-Faf�(fia:ai t8d•�� W as Heigntt ....-tFid.At and Tade sl:., r:i.,;-.. , Hon __�. _ _ to minor.nalni).A:6b .'f4CMR Chepfys PSIi WAR Ttdckreae ._.__._._. - �BrQgd R 520' l' MoE Feuf�iling.....,._.-ice-- �• VaAfor Penel'Atotlzprlte�l jNdap p tfpadbfarmg.wa'ds......-...:............_.-.. ......_(F1g tq•and Tema 6}:c'a{r1' k}+,--::�"�SjA•.o:a - (Fip Notes: 1. Thle dledd'saa8 ba math-0"�q.en8rey,eaxludifyrt�a cpadeo xcaPtba noted N;Y,to vdth dlea E ulremenm A - 6 Wee 51od sp-Ing .. ......_-. :. Ib bnd the fob ng ......:..._.................... tA6. 80CMipbR' ` F0M,f-G#tl!oUId`c. tkma4`E-l' tell' n .. Wau sto7�sseb .: 4.2 E>JeRiOR WALLS .. ....}. _ .. _ . I�. raRWred SRGt�ik'haP'+PefF�9!df;SGude: ✓� 20` Olson. `. Ym:.• _ . . ....-..:............(T. N.:;. n }to' (� ps paru}'e re:14' ........._. 4 .Loadbeenh9 walls......_.-...._. $Irajta P4rF '17 Non-LoatlbeaaA9 Foils......._......._-.._......._._.__....('1'e :, d. All '. Heil 180 Game End Wan smdn9l e- CntnerStud ,Nwn�perFlgurol nd Ftgulfl Fuu Heignt Endwall,S{ilex:.....,..._,_.:_....-- -- _ , FamaROan:Qpenhg he� oP,uj54dl6.n.;ehell he petidilfed e4en a961c gddaQ 6i N@•EaMWll4leigMsheeOdnp ' vJSP Attic Flow le'hg[h._.-.._...._.__.....,.-...._..:..._....fF811) .-..-._.__...._.__.._...._-ftz40N �uhemeiils'hown)rl Tdblda tO dnd=Y.'i": .. .. Gypsum Lellme Ldngth Ili WSP not ds¢�,)-.............+. f-t_.:-u _ .___... r L Thabofbmlydiapiatpld�lor ymd beefnlnblaim 2ln.noMnal•Ih(dale6s Pleca'!'a beefed C2greda. . ard2%4Cwdlnuous Icial Br adl-nF-(FP ----_p-. LSI dfW56-0sye or,x3 eeIDngfurdng atrjpe(r�'18'spadn9^da• 2xl ploddhg®4R apeailn uwla�• Double Top Plald 113 indT Table ........-. e�._- .��"-_.__a._...- - .�--Y'• - svace oord,erp'on(no.'of tsa common neMl•- - . . DOUBLE Top PLATE\ 110-MpH EXPOSURE B WINP ZONE \V.^ . Table 2.Genem/,NalOng Sohedrde. . IrnNT DESCF�iPTION Number of Nulierof, Naji . . ..'. C01ltm6ff:KlaIle BsrTx:Nalla Rebf Framing .2Bd 2•10d' •'each'end . jalooDoirotoROrWT1!i((PA1 2_i8d 31Sd each end > RIM 9oaMfto 14eR9T(End tlaile�' - . ' Wa)tFrerrttng - r -14, - RE4jllfd t,IeLTO At Z4[•b't'END of HEADER .. . . Top plataB Md ectlolte(FaceHtailad) 4-18d 5-16d .At jolnta GL4T. MINI .. ¢p. . - Stud ta, .(Fell 2.18d 2-18d_: 24'o.a BTiJD HEA4ER:BSA# Ap UP(JPS LATERAL.. . Head Header•(F abed) 1 v- . 16d' 5'o.a.elon8 edges ,PAL-.H86HT a4i �PTa' tL6) : 'W• . '. 1.E JACK STUD... �. _ - Eloor FttWnln9. 2" el'.-•. 1 21 L°2 . Nr><'o Joist tb 501,Tap Plate or Gkd¢t(T.otrNaOed)(F1g,14) 4 e dst - .. .wan .7o EN enrol - 44d 2-1od 'eedl end. WINDOW HILL PLATE_ 9 - 2*�X4 '`f- - 416 v rh.mning Eiodd'a'g to Jolat('('�e3lallad) 3.18d' 4-18d: .aeon Wock' :,. 4 54 264 .-•: eF�S o ( II S_6d 4-18d each lot _91a SI8 rYilp'�ate(Yoa•n0 eft) uP Guar .:.•:..•, ., pto Eeaitlpr Glider(Fens-rlelledj 3;d 310d parjdst ' -:.6!.. 3 - raw :Y.`4 haada 1 �\. Jp At on` ePtgj3dam(Ipe NaEed) Mad : 4.18d. pePJdst . ti r 6Bnd Joidt to Jd'9C'[IIR�aaWled)(FIps94) 31 :aged JF�st4?SUI ofTd}T Plate.(Toeaie9ed)(FIg•14) _ 2:18C ed b�-fool } 'I '1-1aG8 9 V9 2 . `.•j':'�'.i•.' •. tM7yp Structural Pena)a •.' .. 53a RSk 5 or tru=sVpeoed Up W lB°ail d led .a edge/ 4° - - - f----' ----- 9 3 ji s I 'T sojA .. �5 17 I - v N.:,: I@ADlai WT11 fe o7 W cae4 Gad 0�0f 18'O,C.. 5 • TRIP ROWS Of bd � IFefta . 8 _ - ___ _ --xr-• - d .:. So i Gable endwag skew rake.Was w/o gable ovEkMang' Bd. •jUd edgd B°Held - .��' taAee AT 9F o.C. 8' of :• '.;' r f© 3 O 4' 1�85 PvbO'. AT Or '(;dijle endwe8 rakeot,ake.truse wl soyc0rt91oW So .,Bd ..4 edgef 4.'fleM 'D r aD:D.•°D•a.e •o•'D`D•°D a ,'6D•a.. O.4 D•a a6•a "D•4 )� 10 4 I 2b. T46 .. . I'; _ ,Ggb)e eodwdll rekd orrdka truss w/krokout 4kloke 8d 10d ,. a '•. e ` •� •. y/ r ,W . D D d•!a d•!a,e•OD d•�D K.. e,!a.e• �d 'a d• o �Pr/� I .'�'• /(� � /�tp }��I�,1/��' �,@p�+ _ Y a A,. n,. C;' SI ILy .7.. : �. 1'!R7Ri+r VY"; fV71Y4j14✓' 'r �L'jii'�V oa - Noll.dladule _ y�plsum Wei thlho d - 5d coolere ad9d .D D D D ANGHOR,AOkTB O 7' .10°fleld a oe 'a `a •a r �• a ad mdridan ,r.;,.%•-s,...- :r e•• e•• 10•!a sd•1 n le,!a 9.'l>S$eXl/4 RCDyTP.,av+P •a a. .ra t# '' 0 -r�1�` pFiFl"IVYfi..�V FXiEB10R. at•3•o .<:% .+ �•"� a118heath188 •e .ad•a .aA'a 0•a:. O•a D•a.•:•D•e D'4 D•a 'a D .. c MEWL., cd"S6vofu al Panels field '• .. a, Btd(jesp p :?A°o.a B. e•. •e•. ,p•. .e•- u• e,! e e a a well 1S':�um Wallboardl7lbanblaard Plulole §d°ooleB} 'P's �10'flahl •D Lro D•n.. do .aD•.'ad•a D'a D•a a.e0•i•.a 6a•.�41 _ 10d �ud es,end •o r v over a .Flbor Sbeatfiblg aD•4_ed'e .a'1_- a'D•a__ad'! .aD•e .4 d_..dd•n .aD•a� r paeaer •ViaadStluvtlrreF,Paggla eli led sedea)lrfleld; - - r• 1'or lees. slid - 18d B`edge/e'i(ald I .e r - . Greater then l'. .. r^ ahamhing - _ •' � �� ���y�,So��i � Idm at > {!1}.Corrosloe re6lstetlt 9.1 gags nal(s and 18 gage steplas are Panittedl.aheak IBC ioreddleonel'requtremenl'e.• a•, .(.=:a��. to- y .> r;i oPd he're*l dmmmonu� S y Y3t t iy al3a R•` Wall:Unless othapisopteled,dm glvpn far naps are cginmgn wire t 2as.ao%and pllsumaeonells of IIF/�P11t _LL• - 'r as eeqq,, diameter entL:6qual ongreater leogthiotha speolltad'am-na is may be substituted unless oelelwise; -� )st i piboh Itad.. dt k_ � � p� t F •t.�... i ' a nff,7 A P� rs(<. 1fy101)::.lAKf =n•qo+ , r ; • Date: Project: Project#: Date: Project: Project#: Location: By Ck: Page of ' ���P>y�� y 9 Location: By: Ck: Page of 1� CrT 1 j 3 1 V 1 f 1 so 4 i S2 -V R 1 � _ f f A