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HomeMy WebLinkAbout0311 WHITE OAK TRAIL - Health 311 WHITE OAK TRAIL, CENTERVILLE A= 192 231 llll N534 oP7�53 HASTINGS,MN IW9No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 3pplitatlon for Misposal 6pstr tt Construction 30erinit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. 3 f( W*i F-o4k-tt AIL Owner's Name,Address,and Tel.No. Lime t MAN" SHICL i Assessor's Map/Parcel (a;). ;1,3 1 31( Installer's Name,Address,and Tel.No. 5-0'2-477-$$7 7 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Rmi"ham_No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _Jj1:57"L_ 4.20A) 0-PX fR i(� �l j Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of SigneA, Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. U I ( 3 ( Date Issued No. I -f 13 Fee r '--_- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliLation for Disposal *pstpm C0ii8trULtion 3pPrmit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System K(Individual Components Location Address or Lot No. 3(1 W*17 0Av_IAAIG Owner's Name,Address,and Tel.No. G`t�tt.�.,t~ Assessor's Map/Parcel (92J 2 I( UJ tM-ts=_ QAV-,-tVA14 <,V I U ' Installer's Name,Address,and Tel.No. SQL$-477 7 Designer's Name,Address,and Tel.No. Type of Building: i Dwelling No.of Bedrooms (v 1 Lot Size sq.ft., Garbage Grinder( ) Other Type of Building PM 1 M A.L. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ..Io 57)"L- QJ& lU p- eox Lqy kl!zm Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore•described on-site sewage disposal system in; accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board•of ea1lh. Signed Date Application Approved by C' �' t, r P r L Date //j I Application Disapproved by Date , for the following reasons Permit No. 2- 0 j cl- E 3 ( Date Issued /o THE COMMONWEALTH OF MASSACHUSETTS `. BARNSTABLE,MASSACHUSETTS CPrtIfitate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by ��®CWL6G 4JT P.8,0 at .311 (.4 OrM Q/44_'_7rAA1L. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 a /L)• /31 dated Ll Installer 1C, & ))(DC Evr /PS Z3Q Designer N/A r #bedrooms A)f,- Approved design flow A A)/ >� gpd r The issuance of this peimit shall not be construed as a guarantee that the system wilt jj tio))n as designed. J f,T Date L� 1 a•�1 Inspector t :/1�1 1 4 i <, ` i : No U �� - .�r Fee T THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal �6pstrm Construction Permit Permission is hereby granted to Construct( ) Repair O Upgrade( ) Abandon( ) System located at .311 LVOC 1s. OAK 19,414., 52EWTBW 1 C e4_F and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. I . Provided:Construction must be completed within three years of the date of this permit Date L/ U rl Approved by � � L'�f t'VV A, ec 4 / Z 4Z)�/ ` Commonwealth of Massachusetts V Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail �t u Property Address ! � Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection t; 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. toFUlUiq��i Important:When ��� filling out forms A. Inspector Information SI 13�-(��- �%x on the computer, �� JAMES :n,' use only the tab James D.Sears =�: _ key to move your Name of Inspector :r cursor-do not Capewide Enterprisesuse * key.the return Company Name - F ..., G 153 Commercial Street Commercial Street ��i�����NSP�`������ ICI Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Q6",�P_A•e� 4-26-19 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts 1 � Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �v= 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete-1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: The system is a 1000 Gal. Tank D Box and pit. Note: Inlet cover under what was a enclosed porch. Porch now is a kitchen. Note: ok per B.O.H. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form lio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail V Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 . t c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in I is less than 6" below invert or available volume is less than '/z day flow ?i1— ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form m h�� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a .� 311 White Oak Trail v Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 1000 Gal. Tank D Box and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2017-16,000Gals g ( y g (gpd))' 2018-27,000GaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1981 Permit #81 -305/2019 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 15" 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.): Pipeing is 4" PVC SCH -40 & SCH -20. t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 5" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 5" below grade. In and outlet baffle's. No sign of leakage or over loading. Note: Inlet cover under what was a enclosed porch. Porch now a kitchen. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form / Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc,): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is new 2019 w/cover at 8". t5insp.doc•rev.7126/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is Centerville MA 02632 4-26-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is Centerville MA 02632 4-26-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit. Pit at V below grade w/ 15"water and stainline at 2'from bottom of pit. No sign of over loading or solid carry over.Wall's are clean. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v w 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 LOCATION ++ SEWACE PERMIT NO. — Y U IN*A ALLER'S NAME i ADDRESS �� 111 U l l E R OR ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED to 1 G i LZ'd LL6b-LLV-909 sesiadje;u3epmedeo d �:170'6LOZaen c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N Estimated depth to high ground water: 35' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: U.S.G.S. well 34'to G.W.. Bottom of pit at T below grade. Bottom of pit at 28'abofe G.W. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 311 White Oak Trail Property Address Nancy Shiel Owner Owner's Name information is required for every Centerville MA 02632 4-26-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included GR/a7f usGS 4- /p �07,w1 l* /li U G -w t5insp.doc rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 116:e- a Cl -.X,3 1 %1 LOCATION .-- SEWAGE PERMIT NO. U -,J V AG - 5£, I INATA LLER'S NAME R ADDRESS BUIL( F I"- A-,A ER OR ER DA T E PERMIT ISSUED DATE COMPLIANCE ISSUED 1� _ � - � S� � � � 0' ���. � ���� � � ��� ,per ff .\ COMMONWEALTH OF ASSACSETTS M HU ..� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA�5� i 1 �l F"I 1 F ENVIRONMENTAL PROT I %y� DEPARTME. T O w�p47 ' ONE WINTER STREET. BOSTON. NIA 02108 617-292-5;00 T `� � 9 •� ` �oTB�NSI 98 F� 1 .•� HOFar'�lF . TRU'DY COXE WILLIAM F.WELD � Secrctar` Govemo: j ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 31/ WA11.e 00h f-aI /CpI,Zit /Jt Address of Owner: Date of Inspection: 9—$'=- W? � (If different) Name of Inspector: IA" q AG All I am a DEP ap r99ved system innspec r puf srt to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: �dryH C/� Mailing Address: lH A, Telephone Number: 162A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete'as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Ll Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The,original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) ,SYSTEM PASSES: 1� I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. . Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or.repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank,-whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Pay I of 10 DEP on the Worid Wide Web: http:ltwww.magnet.state.nia.us/dep ` Printed on Recyded Paper � t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:, 3%% u/h� f 04� /.14, / Owner: ��wA `(T, JYP�SoH Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than,four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation.not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: :3/) W�11 1 C)4/C Owner: ��D�K/C•e,�,l—Ti Ale Isom Date of Inspection: DJ SYSTEM FAILS:✓s'��G You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.3.03. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 ctggged SAS or cesspool. Static liquid level in the distribution boa 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface waver supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. • _ _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no f acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significarn threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST o 0u jru r / Ce" Property Address- Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No JZ _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. L/ _ The system does not receive non-sanitary or industrial waste flow. _ The site ,vas inspected for signs of breakout. _ All system components, exc-fading the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) page 4 of 10 ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ^f SYSTEM INFORMATION Property Addreesssf 111 e OG ✓G� CPh/,r(,l1f e NG Owner. GG�t"'aI'- V, n����j�� / Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: "35J e.p.d./bedroom for S.A.S. Number of bedrooms:2 Number of current residents: (� Garbage grinder (yes or no):,_Q[Q Laundry connected to system (yes or no):4-111-1 Seasonal use (yes no):_ �f0O0Y/1497. 0�� Water meter readings, if available (last two (2) year usage (gpd)• \ / Sump Pump (yes or no): Last date of occupancy:./�q$ COMMERCI.AUINDUSTRIAL: Type of establishment: Design flow: >;allons/day Grease trap present: tyes or no)_ Industrial Waste Holding Tank present: (ves or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no)— Water meter readings, if available Last date of o•-cupancy OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source f i rmation: n� /0-�- 7 rrr� System pumped A part of in ction: (yes r no) If yes, volume pumped: gallons 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ivA;le o A Owner: W"waed T Nl�Siost Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron 1,46PVC _ other (explain) Distance from private water supply well or suction lin? Diameter 4 Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: /;2 Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: .0� s' Sludge depth: 0', Distance from top of sludge to bottom of outlet tee or baffle: N ;1N" Scum thickness: .,410h- o" Distance from top of scum to top of outlet tee or baffle: .6 Distance from bottom of scum to bottom of outlet tee r baffle: How dimensions were determined: �QQStir� Comments: relation to outlet invert, structural (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in ral integrity, evidence of ea e, etc.) r4n h 'C.H N i GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 • � l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / -r-SYSTEM IINFORR-M—ATION (continued) Property Addresss: �// ^te""4,� Y! 694 Owner: �6-1Wa✓Cj d i Date of Inspection: TIGHT OR HOLDING TANK: t7ank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacit\•: gallons Design flow: gallons/da\ Alarm level: Alarm in working order _ Yes; No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) it Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of so ids.cyarryover, evid nce of leaks e,in o or out of box, etc.) !i /s !i c rr PUMP CHAMBER:_ (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.) (revised 04/25/97) 4iiga.7 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3// WA,j-r tVak Owner: Lf/Ar� /v.j�Sv�i Date of Inspection: i8 SOIL ABSORPTION SYSTEM (SAS):1kf�' (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: leaching chambers, number:__ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, si ns of h}, raulic failure, level of ponding, condi ion of vegetation, etc.) , /00 2 L PLe ) o �► of»myfe 11 gH A*' I` CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on 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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3/1 a, 41 1—f 414 Owner: Gtra ,/• Al ebo Date of Inspection: h 9-S--a Depth to Groundwater'*51 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) 1/"'Determine it from local conditions il Check with local Board of health G Check FEMA Maps /Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) /s 673 � yrwc�wafiv co�7O�+v L'/ /s -3j;0 44114 (revised 04/25/97) Page 10 of 10 I t� • r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) / ©�k•�y� ; / C����;/ice,�� Property Address: Owner: �c�/u✓v� � NQIx� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) A II I 1 4 i7% c ' 1i r g��.,- 3 't, 0 � � v / (reviaad 04/25/97) Page 9 of 10 . I THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..................OF... ..g P_7! S _kla dJ �'e---•--_.___.......... ._.._. Appliration for Disposal Works ontrnrtion rrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy .. ... -- --•.. ..................................................... ��77Ae�v,L1e-. •• n-Address o�Tt No. • -_ .. .... A ---------•..... .. Owner Address a ..24... . .................. ... ..... res � ..�. Installer Idds UType of Building Size Lot` i ���...Sq. fe t Dwelling—No. of Bedrooms..............________......................Expansion Attic , Garbage Grinder �`4 Other—Type e of Building _ No. of ersons____________________________ Showers YP g •--------------••--------=- P --(----> -- Cafeteria ( ) � Other fixtures .----•------------------------••---•------------•------•----•----•------••--••-•---••-- ---=-- . W Design Flow........... ................gallons per person per daJy. Total daily flow-...... ll�ons. WSeptic Tank-Liquid capacity ®gallons Lengt ±_ ___ Width__?......... Diameter________________ Depth_ ......... x Disposal Trench—No_____________________ Width___.__ _ .. Total Length........__.I-------Total leaching area....................sq. ft. . ..< Seepage Pit,No._.___.__�.._._.___ Diameter_________ _________ Depth elow inlet_____........... Total leaching area_WP_I.....sq. ft. Z Other Distribution box Dosin tank Percolation Test Results Performed by g _Jr..` .. -_ '__ fir! Date__ __ _ .__.. a p Test Pit No. I._.___��_-----minutes per inch Depth of Test Pit........4........ Depth to ground water......_ �_. . 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---------- f•------------- O Description of Soil....................... ?'� ..... %✓ v_ U --------------------------------------------------- -------------------------•-•-------------------------- •---------------------------------- •----------- -------- •... __••-------- ------------------------ W ----••------------------------------------•-•---••-------------------•-•-•-----•-•-----•-------•-•----•----•-----•-------------•--•----•----------•••-•----•--•-----------•-•-------•----•-------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •---•-•------ -------------------------------------------------------•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in P P ned. by �� of operation until a Certificate of Compliance has been sued the> < DateJ Application Approved By---..... '!r' G/ J`' � .`--- ......... { Date Application Disapproved for the following reasons:...................................-------------------•------•-------------•--•-------------------------...---- ..............................•-•------•--------------•-...-------•-•----..__.._.._-------•-------....._..---•--•-•--•-----•--•---•-------------------••-•------•----••---------•...•-•----••------------ Date PermitNo......................................................... Issued_....................................................... Date - f d No................_....... �' Fmc.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................O F...,, f ......................t Appliration for Di"vii l Works Ifouitrur#ion .e mit Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal Jt /� / / Sys/ Z7//.......� /JJ�G�I� l./!G!L �t `�r� oe 71 /_e9 k_ //L l e ........ .... L c ddres or Lot No. • S UI -1 / C" G, v v , Owner Address ,a Installer Address................ - _" i..........*------- /�U ��Type of Building Size Lo F/....e.....................Sq. fe t ►-� Dwelling—No. of Bedrooms.............. ......._...._.........Expansion Attic A/c)7 Garbage Grinder pa-I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a ---.. --------- Design Flow........... s..r. O gallons per erson er d ' . Total dai flow_;._.._..... Other fixtures .._... Wcv.J g P P jY Total-daily WSeptic Tank—Liquid*capacity/O.. gallons Lengt _-�.�.... Width..'&.......... Diameter................ Depth..&... x Disposal Trench—NQ..................... Width.__ ..Z ......... Total Length......_....:........ Total leaching area....................sq. ft. Seepage Pit No..................... Diameter........ Depth below inlet...._��t........... Total leaching areas�n t.....sq. ft. Z Other Distribution box (f ) Dosin tank k ' 0 l +Percolatign Test Results Per b QY �Gy= ..�'` Date./j,/ y...1 Y 49. Test Pit No. 1.1._ ......minutes per inch Depth of Test Pit-_____.6_........ Depth to ground water................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................... a - --- --- --- ODescription of Soil---------------------- '!.........---- -•---....-•••--•.f`•G v-e• ..........................----•--••-•--•---- -••••----•-------•--- "W U- ........•----•--•--••-••--•-••••••-•••-•----•---------••--------------•---..........-••-••------•--••.....••----•-----------------......---•--. --••-----•--••--•-•..................................... 0 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 TIT12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ssued by the k0ard of rea'1 . d o. /. Application Approved By....................•...............••---•_.. ................................................ -------•-•............................. Date Applion Disapproved for the following reasons:_._.__. ............................... icat ---.......___. --...•....------•-•-------------------••-••--••-----•---•••------•-- Date Permit No.............. ......................•-----......-----•--- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :. - ' ..............OF........................... Trr#ifirttte of Tvmpfianrr THIS,SJO TTIIF,Y, That the Individual Sewage Disposal System constructed (/) or Repaired ( ) bY-•-•------._...�..............-•----.4140- � .. r ---------------•--=--...........-------•-•----- -•----:-----------..-..............--- it......................................................... - -5 w r ,IK;ykaller has been installed in accordance with the provisions of TI / " f Jhe State Sanitary Code as described in the application for Disposal Works Construction Permit No.... .......................... dated-.---------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �) �n / J DATE.. ............................ { �� Inspector_.. /IlL '`i .1 T`-..._.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF_-HEALTH �� Nc �^.�..... FEE........................ Roposal ur Ton#r ion rani# Permission�.kereby granted........ - .. r- to Construct r air (�. ) ii.. div al aggs os S ste �� at No.......... ' P_....�`" `' r / 7.td y .............................................................. ........................................................... Street y as shown on the application for Disposal Works Constructio er it N _ a te ......................................... ----•---. --------- ord of Health DATE.. - ........... . FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -6 � / h / '/ D (: Sla ry r � Zle '-f / nr t l .S i'4:r 777 . ' loop e w/ ,' P jr:�O?? c 1, � �.5 � to A/ orb 7 e j6 Nj aa "pe- Ie7 / 7 �0' 14 E + ../7 4-r 7. 100 110 �o4rsr 3 rad PLANOFLAND { i 4 7 1. ANT FED' V /4kE MASS. VA Of At t) OWN=. BY FRANK IRANK CONERY CO ERY ,p ft 6232 0 " No. 6573 � "j CRANK, CUPIERY § TRMt4�d ST. FG *k HYANNIS, AMASS. OW �STf 9vFR 6TE ?' RE+s►aTWWcD CMMMMR 01 LAND 8UW*IrY{7R Sao suv�'�