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Home My WebLink About0026 WEQUAQUET AVENUE - Health 26 Wequaquet Avenue Centerville P A = 251 142 Omrford, NO. 1521/3 ORA 10% i .._.__,o�.._..._.::_=•_r_x^:.e.,r...nara.i..�a»ae.aruaearmnt.•.:.r,;�me.1>v.uuu,:..,..:.._e...wrr:m,:....v..c...u-w�..✓.rr_�:a¢.m.xr w.d -.wuu.r>T»—.w.r+rs,.:.;,zv_xr ++�.wew,:.•••_ ...src�.u,u+..c....c..w.Cosa.a,.w,.a,wrny",u..uxa,i-o:.....cav,aw,a.,.ne..roe..s.1.a.o,.,..•>mmnw..�..r...,.,�..nu.,,•ra,.n:.0._. 'mil YOU WI5F TO OPEN A BUSINESS? For Your Information: Business certificates[cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which you must do.t y M.G.L.-it does.riot;give you.permission to operate.) You must first obtain the.necessary signatures on this format 200 Main St., Hyannis. Talee the completed.form to.the Town Clerk's Office,1st FL, 367 Main St., Hyannis, M-A 026.01 (Town Hall) and get the Business Certificate that is required by law. DATE: 03 30 If Fill in please: ' APPLICANT'S . YOUR NAME/S: hYI A,�SO BUSINESS YOUR HOME•ADDRE v U t NX v �� Z MR :L''11'-1 � TELEPHONE 4 Home Telephone Number u E-MAIL: U5� OR EIN #: y�p — 53GrJ NAME OF CORPORATION: CJ TYPE❑F BUSINESS NAME.OF-NEW 13USINESS MAX)( PA I h i VI U A�n OCCUPATION? - YES NO � _ qZ=,___,Assess1ng)IS THIS A HOME / � I 1ADDRE55 OF BUSINESS- b in9E CR Ue -� 'L f✓� i MAP PARCEL NUMBER � w of C the rules end re ul'ations of the To n When startin a new business there are several things'you must do in order to be 1n c,?mplience with 9 g Yarmouth ' obtaining the information you may need. You MUST GO TO 200 Main St. - [corner of Yarm u This form is•inten'd'od to 'assist you In g . Y Barnstable. Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business In this town. 1. BUILDING CO MI 51 NER' OFF] This individ b e in m f n er 't r quiremerits thotpertaln totiiistype of business. MUST COMPLY WITH HOME OCCUPATION RULES AND RLGULAT40NS, FAILURE TO A+orize ig at ** COMPLYMAY RESULT IN FINES" MMENT f ,. 2. BOARD OF HEA H This individual has been informed oftYl e permit requirements that pertain to this.type of business. IIIIU t CbMPLY WITH A L f 7�,":& HAZARDOUS MATERIALS REGULATIONS Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS. Date:63/30/ /9 TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: Mpo obi n-h n 6 BUSINESS LOCATION: Zi(g (, ,. QoPrQj)(,t- k� c9263Z U1A92riIIOINVENTORY MAILING ADDRESS: TOTAL-AMOUNT- TELEPHONE NUMBER: �-0y Z 33 O 16 q CONTACT PERSON: t AI ,yz�Ue( W Wvn0 _ EMERGENCY CONTACT TELEPHONE NUMBER: !!��98 Z�(j MSDS ON SITE? TYPE OF BUSINESS: AIn1 & INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts(Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers C� Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staffs Initials Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,• � 26 WEQUQUET AVE Property Address LOVELETTE .. Owner Owner's Name information is CENTERVILLE ✓ MA 02632 10-26-15 I. required for ` 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name VQ P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 10-26-15 Inspe or'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. b U S t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): T❑ he system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health.in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Tide 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 wM °r 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® El 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): ASSESSING DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: A 1000 GALLON SEPTIC TANK AND 2 LEACH PITS WERE LOCATED Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2013---178 2014---200 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM ,a°'p 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown 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): TANK AND 2 PITS NO D-BOX t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: UNKNOWN Were sewage odors detected when arriving at the site? ❑ Yes ® No 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): Depth below grade: 2.75 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: APPEARS TO BE 1000 Sludge depth: MODERATE t5ins-3/13 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 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 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 Scum thickness MODERATE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING AND RISERS ON INLET AND OUTLET 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ 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•3/13 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 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): NO D-BOX FOUND Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4M s 26 WEQUQUET AVE Property Address LOVELETTE Owner Owners Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 IN SIERIES ❑ leachingchambers 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.): BOTH PITS WER FOUND AND OPENED THE PIT CLOSEST TO THE TANK WAS FULL AND THE OTHER PIT WAS OPENED AND AT TIME OF INSPECTION HAD ABOUT 1 FT OF WATER WITH NO SIGNS OF FAILURE OR SURCHARGE STAIN LINE APPEARED TO BE AT ABOUT 2 FT FROM INLET INVERT. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �,M ,•�''� 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 26 WEQUQUET AVE Property Address LOVELETTE Owner Owner's Name information is required for CENTERVILLE MA 02632 10-26-15 every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE L�TION_�� G�VAD�t� SEWAGE# VILLAGE, C£/'r- ASSESSOR'S MAP 8t LOT IL- I/ �NCR S NAME dt PHONE NO. SEPTIC TANK CAPACITY LEACHING FACU=:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER 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 (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A f __7 � 0 � a. to s. 0 . ° y! O pir f a- J http://www.townof bamstable.us/Assessing/HMdisplay.asp?mappar=251142&seq=1 10/29/2015 COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR[,. A ION _ GE!' SV.V G2JMe350 MAIN STREET 0 bAr(q,,6,, WEST YARMOUTH,MA ALTH UEPf 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 7' PART A CERTIFICATION MAP 251 PAR 142 Property Address: 26 WEQUAQUET AVENUE (SAP CENTERVILLE,MA 02632 Owner's Name: BELL,JAMES PARCEL -- Owner's Address: 26 WEQUAQUET AVENUE LOT AUGUST 12,2002 Date.of Inspection Name of Inspector: (please print) JAMES D. SEARS Company Name: A& B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector sha 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 tot he 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 1 t � Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: N/A 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 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 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 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: Title 5 Inspection Form 6/15/2000 2 I Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to deternine 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 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 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 coI'form 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: i Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 D. System Failure Criteria applicable to all systems: N/A 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 X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than''/z 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) 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: N/A To be considered a large system the system must service 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 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 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? X 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 X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X 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)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 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: 2 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): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 35,000/2001 27,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sqft,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: N/A 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN AGE OF SYSTEM. NEW PIT IN 1986 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 BUILDING SEWER(locate on site plan): X Depth below grade: 2' Materials of construction: Cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 33" 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: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 16" Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.TANK AND OUTLET COVER 33' BELOW GRADE.INLET COVER 8"BELOW GRADE.INLET BAFFLE,ONE OUTLET BAFFLE.NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 TIGHT or HOLDING TANK: N/A (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: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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: N/A (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.): Title 5 Inspection Form 6/15/2000 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: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X 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.) LEACHING IS TWO PRE CAST PITS.PIT#2 NEWER PIT INSTALLED IN 1986. PIT#1 LEVEL UP TO OUTLET LINE,PIT#2,2'WATER IN PIT.NO SIGN OF OVERLOADING. CESSPOOLS: N/A (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: N/A (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 5 Inspection Fotm 6/15/2000 9 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: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 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. £c,� / o I Aos o yi• o Title 5 Inspection Form 6/15/2000 10 a Page I 1 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 WEQUAQUET AVENUE CENTERVILLE,MA 02632 Owner: BELL,JAMES Date of Inspection: AUGUST 12,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 30 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: Observation site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.I.S. �b I 30f. 13 Title 5 Inspection Form 6/15/2000 11 TOWN OF BARNSTABLE LOCtiTION cU SEWAGE # VILLAGE C 1'A'T ASSESSOR'S MAP & LOT i ti.SPFC7a,e r IN&T41,1=€R S NAME&PHONE NO. 1lB C��iy C O, SEPTIC TANK CAPACITY LEACHING FACILrFY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER 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 (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ^�•a r 1 ► �,T pir ? Fmc ............... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7�wr................OF.....1. qMAUlle.......................................................... Appliration for Disposal Works Toustrurtion Famit Application is hereby made for a Permit to Construct or Repair (* an Individual Sewage Disposal System at: (a ..........., .Q............rx U ....................................................................................... -i *cation:Address 9.t or Lot No. AL .............. .....use Ala .4 ,,,,.. . .............................................. &C Owner 0 Address ..................�j ....................... ......yar.0;A..........0..................................................... -_ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................3:........................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers Cafeteria ( ) Other fixtures .......................................... ' ........................................................................................................... Design Flow............... '" - ------------gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capa'''..city........%.gallons Length................ Width__..........._._ Diameter................ Depth_....__..._..... Disposal Trench—No..................... Width.................... Total Length..._................ Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter............_._..... Depth below inlet_.............._.... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit___.__..........._.. Depth to ground water_.______.._._........__. Test Pit No. 2................minutes per inch Depth of Test Pit___................. Depth to ground water.__......_......._..___. ............................................................................................................................................................. 0 Description of Soil.................................................................................................................................................................... ......................................................................................................................................................................................................... U ............................................................................................................ ....................... ... ... U Nature of Repairs or Alterations—Answer when applicable_ ---Igqq. ".0 . ....... ... -------- ----pl- r �C'i........................................................................................................................................................................ Agreemenr The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'JITLIE 5 of the State Sanitar- Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has 11!en issued by the board of health. Signed -- -----11---- z��--------------------------------------- --- ------ Date --------------- Application Approved By.... e. ................. ------!9Cq------ Date Application Disapproved for the following reasons:................................................................................................................. .............................................. .......................................................................................................................................................... Date PermitNo................. ........ ........... ....... . ........... Issued........... ............. Date ---------------------- No...S? ._....1-�„'f' Fss... ................... THE COMMONWEALTH OF MASSACHUSETTS ++ BOARD— -�c�, OF HEALTH _.._..�!.OtPY1..................OF,...!e-=,r�72,:., fr)! .......................................................... Applirutiun for Disposal Works Toustrnrtion JIrrutit Application is hereby made for a Permit to Construct ( ) or Repair (, ) an Individual Sewage Disposal System at: Ej !Q-«jn�:. i�Wv . 011,,teruj1fie, .----------------------------•---•------.....-------------------------•--..........--------....--- --• ------ ................. - -'-"�� Docation-Address t or•I of No. r ....._._...E2tr^i., lGgs �uQ ................................ u l c:� ......! . ,. _tcr... 1 t 'rya+�Pr-+...lit-e_--------.........---- Owner , 1 JJ 41 f7' l�r,,,ii Cc� 350 I)'ff.l rl .`} v e t l�!•fdYlGtc. Address ------------------------------------•-•---•-----•-------•----------------•----••-----•--•--•-•--._ .......-•-••--••.._..._.......-•--............-•-•..-'-p='•-•._.r ......................... Installer Installer Address UType of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms______________..................._..........Expansion Attic ( ) 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. 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.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •-•--•-•-•••-•---------------•-••-•••••••••.._..••-•••••••-..__.....•••••-•--•--••--------..._-•••--......................................................... 0 Description of Soil..............................................................................................................---------------------------------•-•••-•••-...._..----- V --------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-..--------------------•••--- W x --•---•----------------------------•----••-•-----------•--------••••--••••-•-----------...••••--••-•----•-•-••-•-----•-----•--•----•-•-•••--••••----••-•---- --------- --! ----- V Nature of Repairs or Alterations—Answer when applicable._-7>1_.'4t44____� =--------------------------------------------------•--------------•. ------•--------------•------•----••-------------.-.-----•---••----•••-•••--•••••----_.........._. Agreements: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITA L 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. Signed =s�:__KU _0�1,00z4e .Q 3- I I- F,(n ------------------ a 1 Date Application Approved BY-- C"^t__✓ .- "`................... =I l ' ` rs....... Date Application Disapproved for the following reasons------------------•------------------------------------------------------------------• ........................ --------------------------------------------------------------------------•--•---------•--.._..._..--------•--••--•••-_...••-----••----••••----••--•--•-------•-----•••--•----•-•---•-•••--•--•......••- Date Permit No...... �........�. .I!---•--•-••-•- Issued--•---------------------------------•--•----•-••------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..�acNn.....................OF......c-ar,,r»5`�c� .............................................. Trrtifiratr of Tuntpliaurr THIS I 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY.................. ----)L •'3.-'1---------------•--...._......_...-----------------------•----------------.........-----------•-----------•-•---------......._._....-----.....---•------- Installer at... -`•�=--......---....`-... ? rl�' sj�--•--•"�1s ------ A --------•------------- -- has been installed in accordance with the pro isions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-_____7S_S�CcT___-._f_�__(____ dated_..= /1. �-_ .................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W1 L FU/i$CTION SATISFACTORY. DATE......... -------�-,/.-'6---------------------•---____-__---------•------- Inspector.....------ ._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. J7 O .......................Cr .......... ..................... ,..... � .--._.......................................... NO G.� �J r....... FEE.___. .. Disposal orkg Tonstr ion rrntit Permission is hereby granted............. ` '::f?! &-...................................................................................................... to Construct ( ) or Repair ��<a Individual Sewage Disposal System atNo-----� --(,P-----�K�.102 -164.........-. .............................................................---......------- -- Street ec�� --- as show' on the application for Disposal Works Construction Perm�i t.N �76 V _;_f__ Dated____ �( � ----...•--•..._._._.... �^ Board of Health DATE._.. _��_ ...0. FORM 1255 A. M. SULKIN, INC., BOSTON aL0.! AT SEWAGE FERPIT NO. VfLLAGE If--4STA LLER'S PIAM, E A ADDRESS U I L D E R OR OWNER O A T E P E R M I T I S S U E D DAT E C 0 M P L I A N C E ISSUED 3/j5ZM ��C - � _ ____ �� b �� dS� a6 ,/ -�, o � _ v,- o- >, e �� :� a