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HomeMy WebLinkAbout0329 WHITE OAK TRAIL - Health 329 White Oak Trail Centerville P---- - R 192 233 �m UPS 12543 NOS3LOR {.° Commonwealth of Massachusetts . ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important: A. General Information When filling out forms the computer,use 1. Inspector. only the tab key to move your VANCE STEVE YOUNG cursor-do not Name of Inspector use the return key. Company Name BOX 1592 Company Address MANOMET MA 02345 'P Cityrrown state Zip Code 508 759 5603 S1686 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 twSectioln=15.340'.of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails.; ❑ Needs Further Evaluation by the Local Approving Authority 11/16/08 r�3 1 pector's Signature Date r 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. WHITE OAK•08= Title 5 Official tnspechon Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 329 WHITE OAK TRAIL Property Address GMAC Go REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. citylrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or 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 WHITE OAK•08106 Title 5 Official Inspection Form:Subsume Sewage Disposal system•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y` 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 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 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. WHrrE OAK•08106 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 329 WHITE OAK TRAIL Property Address GMAC Go REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. Citylrown 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.): TANK INTEGRITY OK INLET AND OUTLET BAFFLE OK .LIQUID IS LEVEL WITH THE OUTLET INVERT Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): WHITE OAK•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;•�y< 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO,MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) RISER TO-12" If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8X5X5 Sludge depth: 4" � Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" " Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? MEASURE STICK WHITE OAK•Oa106 Tide 5 Official Inspection Fonn:Subsurface Sewage Disposal Sy stem•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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) (f yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (If known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site? ❑ Yes ® No WHrrE OAK-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `t 329 WHITE OAK TRAIL Property Address GMAC Go REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(d yes separate inspection required) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available past 2 years usage (gpd)): 0 ®00 Sump pump? M Yes ® No Last date of occupancy: APPX 9/1/08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Documentl•08/05 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is BARNSTABLE MA 02632 11/16/08 required for every page. Cftylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate ayyw 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 WA) ® ❑ 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: Z ❑ 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)] WHITE OAK•08M Title 5 Official Ins n Form:Subsurface Sewage Disposal pectin g System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 WHITE OAK TRAIL Property Address GMAC Go REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. City/Town State Zip Code Date of Inspedion B. Certification (cunt.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria east 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 11 of a public water supply well If you have answered Byes'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. WHITE OAK•08M Trite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Flame information is required for BARNSTABLE MA 02632 11/16/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All 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'/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. WHrrE OAK•01106 Trite 5 Official Inspection Form.Subsurface 's Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. City/Town state Zip Code Date of Inspection D. System Information (coat.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locale 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(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No WHRE OAK•08106 Title 5 OflidW Inspection Farm.SubsuAace Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO,MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 6" OF EFFLUENT IN PIT. STAINING ON WALLS OF PIT TO APPX 41NDICATING NO SIGNS OF HYDRAULIC FAILURE WHITE OAK•08M Tttte 5Offrcial Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 329 WHITE OAK TRAIL Property Address GMAC Go REMAX ASSET MGMT. FOXBORO,MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): WHITE OAK-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,dwj329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. RoA(Y Q f ,5 WHITE OAK•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 329 WHITE OAK TRAIL Property Address GMAC c/o REMAX ASSET MGMT. FOXBORO, MA. Owner Owner's Name information is required for BARNSTABLE MA 02632 11/16/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 29' 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: PER BOH MAP ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: PER INFO ON FILE WITH BOH WHrrE OAK•O8M6 Title 5 official btspechen Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO RECEIVED SEP 2 12004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION q Property Address: 3a 9 w r e p�,�, T' � AP eo ,rvj t 06-63a ARCEL Owners Name: Owner's Address: Date of Inspection: Name of inspector.(Tease print) Qy''� PZce Company Name: ,F 00 0 — L C Mailing Address: 0 ,Z tM A Telephone Number. 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 n training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP on my aPPrnved system inspector pursuant to S 15.3�It1 of Title S(310 CMR 15.QtN1). The system Passes /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: /' Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of com�letirg this inspection If the system is a shared system or has a design flow of 10,0M 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. Notes and Comments *"""This report only describes conditions at the time of ins time.This ins pection and under the conditions of use at that section doer nut address how the ryOCTO will perform in the future under the same or different conditions of use. Page 2 of I t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: LIA,;�e r✓, � d-G3� Owner: Date of Inspection: Inspection Summary; Check AJ4C,D or E!ALWAY complete all of section D A. Syste asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 qr in 310 CNIR 15304 exist Any failure criteria"evaluated are indicated below. Comments: & System Conditionally passes: '"Cot more system components as described in the"Conditional • re ed The stem u Pass section need to be replaced or Pau sy 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 fo explain llowing statements.If"not determined"please The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structural) unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will existing tank is replaced with a complying septic tank as approved by the Board of Health, Pass inspection if the "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 rcdwved distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year Pass inspection if(with a y to broken or obstructed ppe(s).The system will approval of the Board of HealtLuJ: broken pipe(s)are replaced obstruction is removed ND explain: page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM _ RM PART A CERTIFICATION(conwnied) Property Address; Sol �1, O q l✓ T�a�� Owner. I✓hei oZ Date of Inspection: D C.,� Furth"Evaluation is Required by the Board of Health: 1/V Conditions exist which require fiuther evaluation is failing-to protect safe h by th a Board of Health in order to determine if the system ty,or the environment. L System will pass unless Board of Realth determines in accordance with 310 CMR M303(1)(b)that the system is aot.fiumdouing in s manner which will pyotect public health'_Wetg and the earirediumt: — Cesspool or privy is within 50 feet of a surface water — Cesspool or prrivy is within 50 feet of a bordering vegetated wetland or a salt marsh 2, System will fail unlCM 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 I(X)feet of a surface water supply or t nbutaa y to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. — The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a Private water supply Well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile orPnic compounds indicates that the well isf=frosa the presence of ammonia nitrogen and nitrate nitrogen is pollution from that facility and 'failure criteria.are tri g �to or less than 5 ppm,provided that no other ggered A copy of the analysis must be attached to this form. 3. Other, �� r3 I page4ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES SMENTS SUBS MENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 Owner. w,�, 6 3a1 Date of Inspection; J p D. Syatem Failure Criria applicable to al!aystema; • You must indicate es"�" "y no to each of the following for all inspections: Yes No �acicup 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 SAS or cesspool waters due to an overloaded or — ogged Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or —�,AqWd depth in „ cesspool is less than 6 below invert or available volume is less than y= ,flow /� pumping more than 4 tunes in the last year NOT due to clogged of obstructed 9f tunes pumped pipe(s).Number Any Portion of the SAS,cesspool or privy is below high ground water elevation Arty Portion of cesspool or privy is within L00 feet of a surface water supply or tributary to a surface water supply. Portion of a cesspool or privy is withia a Zone t of a public well, / portion of a cesspool or privy is within 50 feet of a private water supply Any Poctioa of a cesspool or privy is less than l00 feet but well. supply well with no a i;rsyste thaa 50 feet from a private water acceptable water quality analysis. [This system passes it the well water analysis, Performed at a DF.P certified laboratory,for coliform bacterit 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 lei are triggered.A copy of the analysis must be a I than S ppm,provided that no other failure Criteria ttached to this form.) (YeslNo)The system faillL I have determined that one or more of the above failure criteria e.,dst 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 We failure. E. Large Systems: To be considered a large system the system must serve a facility with a desire flow of 10,MN1 gpd to tS,01N1 gpd You must indicate either lyes"or"no"to each of the following; . (rhe following criteria apply to large systems in addition to the criteria above) y no system is within 400 feet of a surface drinldng water supply the system is within 200 feet of a tributary to a surface drinkng water supply system is located in a nitrogen sensitive area(Interim Wellhead protection Area—IWPA)or a mapped 7 _e It of a public water supply welt If you have erect"yes"to any question in Section E the system is considered a significant"yes" in Section D above the large System has failed The owner or operator of any Lar considered me aanswered significant threat under Section E or failed under Section D shall upgrade L5.304,The System owner should contact the a osystem in accordance with 310 CMR appropriate regional office of the Department, Page 5 of 11 OFFICIALINSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: geve 0,1 Owner. ✓12 . Date of Inspection: ov Check if the following have been done.You must indicate es"or"no"as to each of the%nowin , Yes No / t/ information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks qskm received normal flows is the prevu=two wean period Have LvBmhmm of water been introduced to she rystem recently or as part of this inspection Were asbuik 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,opt,and the mterior of the tank inspected for the condition of es or tees,material of construction,dimensions,depth of liguicL depth of sludge and depth of scam mauiWnanceof sewage o msal ,if differeai fmm owner)provided with information on the proper The sue and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes w� — lastwg information. For example,a plan at the Board of Health. v Determined in the field(if any of the faihue criteria related to Part C is at issue approximation of distance is unacceptable)(310 C vM 15.302(3)(b)] �c S page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION rty Prope Addr / ess• �o` �'i l e 0., f i T✓'oyL Vs Owner. Date of Inspection: 3 0 RI SIDENTL4L FLOW CONDMONS Number of bedrooms(design): Number of bedrooms(actual): 7 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence hake a garbage grinder(yes or no): AM Is Laundry on a separate sewage system(yes or no):W [if yes separate inspection Laundry system (y or no):AVrequired] Seasonal use:(yes or no): Water metes readings,if available(last 2 years usage(gpd)Y Sump Pump(yes or no): Last date of occupancy:�/tom 4—- COMMERCLUANDUSTRIAL Type of establishment: Desiga IIow(based on MO CMR I5.203): end Basis of design now(seatss/persons/sgft,etc.): Grease trap present.(yes or no):_ IndastrW waste holding tank present(yes or no): Non-sanitary waste discharged to the True 5 system(yes or no):— Water meter readings,if available: Last date of occupguey/use: OTHER(describe): Pumping Records. FO GENERAL INRMATION. Source of information: eCtWas system punned as part of the inspection If yes,volume pumped (yes no): _--gallons--How was quantity pumped determined? Reason for pumping: T'��]� YSTEM .. . tank,distribution box,soil absorption system —Single cesspool _Overflow cesspool —RivY _.Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovrom system ternow a technology. attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Try tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components date ns�cd(if(mown)andsource of information: """'/ 0 "�✓ Were sewage odors detected when arriving at the site(yes or no): -- i Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued Property Addre=IW� ,.L�/�Owner. /7'� t/'1Date of Inspection; 3 p BUELDING SEWER(locate on site plan) Depth below grade; 02 4 ✓� Materials of constnution: iron _top- �VC o (explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting evidence of leakage,etc.): SEPTIC TANIL•_L"In . on site plan) Depth below grade: Material of construction,other(explain) ��crete metal._gym_polyethylene — If tank is metal list age:_ Is age confirmed by a Certificate of C certe) / Compliance(yes or no);—(attach a copy of Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or bafile.,3_ Scum thidlmess: i# Dis:tance from top of scum to top of outlet tee or baffle:Distance from bottom of scum to bottom How were dimensions et tee or e: determined; 0!� a c�s v i C G Comments(an pumping recommendations,inlet and outlet toj7or baffle condition, qleakage. structural integrity,liqurid levels fated to utl et invert,evi nce of e .): Cis t✓'1.c, � GN� qNd � ON GREASE"TRAP: (locate on site plan) Depth below grade; Material of construction; — — --_concrete meta! fiberglass (explain): polyethylene—other Dimensions: Scum thickness;_ Distance fvm 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 rote as related to outlet invert,evidence of leakage,etc.): integrity, liquid levels I , page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addnesc 3)9 'of ©G�,, ram„ ✓vc Owner: 1j(r"10' Date of Inspection: 9 TIGHT or HOLDING TANK: (tank must be pumped at time of inspec-tion)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethplene o thel(expL•,;n): Dimensions: Capacity: eanons Design Flow: Alarm prcaent(yes or no): Alarm level: Alarm in working order(yes or nor Date of last punVing: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:�(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:/y (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 ap purtenances,etc.): tJ Page 9'of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pmperty Address; 302 9 owner: Date of Inspection: 3 0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not looted explain why: �Icacg l.�nmbr:l s I number: leaching ga1l�;�,number leaching trenches,number,length: lawhinglields..number,boas: overflow cesspool,number nmovative/alternatiYe system Typetname of technology: Comments(note condition of soil,signs Of hydraulic failure,level of n etc.)-. po ,�P�fl,condition of vegetation, ^ 'Iflo o« �, o r� CESSPOOIS&(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 constriction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:4L//Oocate 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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Addn= n ra, L. Date of Inspection: 3 0 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. B a 4 a9/ 30 -� 93- y i 0 r i I Page 11 of 11 ` OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: 9 Gv h, ©a k/ 7-/,C,; L rti10 �1 Owner. n2r Date of Inspection:_ 0 SM EXAM Slope Surface water Check cellar Shallow wells Estirrurtexl depth to Bound water aZ 9. feet a, Please indicate(check)all methods used to determine the high Bound water elevation Obtained from system design plans on record-If checked,date of design plan reviewed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-xplain: V`1 of e S x C 5 Checked witch local excavators,installers-(attach documentation) /1 CCe.SSod UStJS dat.117�Se-C�plalII: O� A You must be h c a'� you,establish fi then r groundga atioo: .-0 va - r o on /'.. c4e G, S. ,S 15 H✓t w.. l o io �A� ---------------------- 9. �� (� d 9 4. t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a t t r �O t 4 TITLE S OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION f� Property Address: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 I . c�a. as� �� } 5� ►J Owner's Name: MR.CALIGORIS V Owner's Address: 71 MICHAEL STREET,FITCHBURG,MA.01420 Date of Inspection: 8i2i01 RECEIVED Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS AUG 0 7 2001 Mailing Address: P:O.BOX-2119 TEATICKET,MA.02536 TOWN OF BARNSTABLE Telephone Number: 508-564-6813 FAX 568-564-7270 HEALTH---- 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 Furthe aluation by the Local Approving Authority Fails Inspector's Signature: Date: 8/2/01 The system inspector shall submit 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 now 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. Notes and Comments rz SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. . 4 ****This report only describes conditions at the time of inspection and under the conditions of use at that time.'Phis inspection does not address how the system will perform in the future under the same or different conditions of use. i F. Pape 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t; CERTIFICATION (continued) A. Property Address: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS „ Date of Inspection: 8/2/01 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 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: t' SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.. B. System Conditionally Passes:t.. _ One or more system components astdescribed 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. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a 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: n/a n/a The system required pumping more`tfian 4 times a year due to broken or obstructedpipe(s). The s stem will ass Y 9 P P g Y Y p inspection if(with approval of the Board"'of Health): _broken pipe(s)are replaced obstruction is removed ND explain: n/a t.. i, , r [9 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS Date of Inspection: 8/2/01 y C. Further Evaluation is Required bty' 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: •F' _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh z 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 tarek�and soifabsorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface4ater supply. t•: _ The system has a septic tank and SAS,and the SAS is within a Zone I 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 tanit'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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a kA Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 329 WHIYTE OAKTRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS } Date of Inspection: 8/2/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool'br privy.i§within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ]This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design 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 _ X`the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a,tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well .,, 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 systeiit'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. Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS Date of Inspection: 8/2/01 Check if the following have been done.`You-'must indicate"yes"or"no"as to each of the following: ZY Yes No X _ Pumping information was provided 6y 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)on the site 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)] 5 Page 6ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS Date of Inspection: 8/2/01 FLOW CONDITIONS RESIDENTIAL IV 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): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): YES Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a = ` Design flow(based on 310 CMR"15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present.(yes or no): NO Non-sanitary waste discharged to the,Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a 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: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a 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 `1 system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a 1 Approximate age of all components,date installed(if known)and source of information: 18 YEARS Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS Date of Inspection: 8/2/01 BUILDING SEWER(locate on site,plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting;evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed,by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 1" Distance from top of scum to top of outlet tee'or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined:20 PVC Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND APPEAR TO BE FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE ,.o , GREASE TRAP:_(locate on site'plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS Date of Inspection: 8/2/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a . s DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): DISTRIBUTION BOX APPEARS TO BE'STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a t} u 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: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS Date of Inspection: 8/2/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: nla n/a overflow cesspool, number: n/a n/a :innovative/alternative system •;Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT APPEARS TO BE STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. THE LEACH PIT HAS NEVER HAD MORE THAN I FEET IN IT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a F+. n Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WHIYTE,OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS Date of Inspection: 8/2/01 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. rrcAl R AAFA a�S 10 Page l l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 WHIYTE OAK TRAIL CENTERVILLE,MA 02632 Owner: MR.CALIGORIS Date of Inspection: 8/2/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators;installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12 FEET i S u ,t ?? TOWN OF BARNSTABLE L( TIO'N J�Q GlJ�f1 n� ® R'�/�-/L SEWAGE # VILLAGE C�/%,Or5 , YZA-L.� ASSESSOR'S MAP &SLOT 3 L*cTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (ty� (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the:. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist. within 300 feet of leaching facility) Feet Furnished by OA AA PA fl f�� yet "; I TOWN OF BARNSTABLE LOCATION JP? (.�4i7'�� C�i1/C r�i/1zl� SEWAGE# /lo� a�✓.� VILLAGE C FdVr9A V I J-GAr ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY IeO6 LEACHING FACILITY. (type) (size) / 9 O 0 NO.OF BEDROOMS E� OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /O 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) JJ Feet FURNISHED BYA-/liC� �R©�/Y o��� Q 0 C OI o �� 3 �'q.8 a � ��''"q"� _. 3 ,�,� � �� . e . . .� �// t 42 � IV Y aL'3,o,�� L 0 C T 10�1 yA CE PE RMITy NO. ,eaVI AG E IN TA llE 'S NAME i ADDRESS tU1lDER 01117 R DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �6k-fLe� i � Ao L CATION SEWAGE PERMIT *0. INSTAeLLE 'S NAME i ADDRESS of I t UIL E R OR NER DATE PERMIT ISSUED LQ DATE COMPLIANCE ISSUED v.< 7 .. /.. � � �� .a � � � __... _ .. Lt ATION SfwA ! C E f RMIT m0. . - r INST LLE 'S NAME i ADDRESS �3 • 9 Itf E R OR N EA PATE PERMIT ISSUED . 14 ., 6 i DAT E COM►LIANCE ISSUED �1 r Iga Av Zdw A GE PERMIT N0. 5P v1. _ INM A LL EP'S NAME i ADDRESS o + UI CDAEJI OR .. R � 1 i DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i i YdL4,�L ,e � I 4,40J I No.... .1 3.P THE COMMONWEALTH OF MASSACHUSETTS �. BOAR® OF H EAt_ H ...........OF.........� .� .. .. .._ ........... Allp irFa#ion for Dispm a1 Workii Tonstrnrtion Frrmit Application is hereby made for a Permit,to Construct X or Repair ( } an Individual Sewage Disposal System - ....�1..t .� e --........-- ---•- ... .._ .. ' ......--- Lot No �°rf✓S t1..Y..t....-.-.--.-.--- ..i LL s a oc -.Addres ---••••-••-•.--•- ...... Owner - r..----- ...... • .................... Installer Address � � . .__7®Type of Building Size Lot_.y_.,,.__ __ ..Sq. feet U Dwelling—No. of Bedrooms............ .. .....Expansion Attic NO Garbage Grinder MO Other—T e of Building .... No. of persons............................ Showers — Cafeteria Q' Other fixtures .------•--------•---------------------------•--• ••--•••••----•-•----•-----••------•-- ---=---- ¢,�.._... F gal w Design Flow.............. �� —................gallons per person per day. Total dailyflow.:_........ lobs. WSeptic Tank—Liquid capacity/AV gallons Length h.tC.'... Width....6......... Diameter______________ _ Depth...... x Disposal Trench—No..................... Width..........p........ Total Length................._..Total leaching area....................sq. ft. Seepage Pit No......I............ Diameter........1_Q..... Deptl below inlet._itT...... Total leaching areaee Z,�Sq. ft. Z Other Distribution box (�) Dosing tank )o Percolation Test Results Performed by--- ....s. la�7 .tr......._ '.................. Date...A.ov - - fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a Test Pit No. 1........ minutes per inch Depth of Test It_.___ De th to ground water... . �........__: • .••--• ................................ •-••••••-•......} ----.....- --------- --------------•------------------------------------------ O Description of Soil....&5,a: 1 r � Q � _�.... ..._f� _ �7�1 '1. x w U Nature of Repairs or Alterations.—Answer when applicable................................................•....._........._......._...___...._...._...... ---------------------------------------------------••---•--.........-----------------••-•-------------------....--------------------....------------....------------------------------.............••••. " Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'ITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by th of health. Signed. ........ ... ..... ........ ................................ -------------••••.••--• Date Application Approved By •_._ , •. ... ...... . ................................... .../ :2�slz----------- Date Application Disapproved for the followin ea-sons......•••••----•--••-••••••-•••-•-•--••-•••---•••------••---••••••••--•-••-••-•-••••......--•-••......•••--..._.. ----------------------------------------------------------------------- Date PermitNo........A�............1_................................ Issued....................................................... Date r =! r FIM ..�.�..� $ ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL�H / .............�.417.2........._OF......... Q.�.�7..� Q-�......e.....------• Appliration for Dispusa1 Works Tonotrudion Prrutit Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal System t ................_....._..._..._............. ... .......................... ................--•--------•--ov ----------•---•-----------`5---- Locat A dress Lot No. Owner C�� ddres" W I................................................ .....I --------------------------------- �t t Installer Address�� 99 7_ UType of Buildingw Size Lo ._:___,t....................Sq. feet 1•-1 Dwelling—No. of Bedrooms......... ...........................Expansion Attic/< )o Garbage Grinder el )o aP4 Other—T e of Building _..... No. of persons........................; Showers YP g ----•----------------- p --- ( ) — Cafeteria ( ) d Other fixt es -------------------- �j W Design Flow........... .................................gallons per person per day. Total dailg flow...._....: 1__ ...............ga WSeptic Tank—Liquid capacity/QPP.gallons LengthE4 ..._.:Width_,.6......... Diameter________________ Depth....6......... x Disposal Trench—No..................... Width......_..y......... Total Length................f.. Total leaching area....................sq. ft. Seepage Pit No......�............. Diameter.......ZIQ.._. Deptl below inlet.'�....._. Total leaching areaieM4...sq. ft. Z Other Distribution box (� ) Dosing tar !6/)0'—' Percolation Test Results Performed by____.:.�.. A]2_.___Y. .____..��^'� Date.. 5� .. � Test Pit No. I....... ._minutes per inch Depth of Test Pit____ ____________ Depth to ground water-__��._�l.�W� 4, Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ -J/...............................-.................- ..._-- -------- ......................................................... Description of Soil.... Q_...1.4�_r-....... ._vim.f! ' ` 4 /'_ �7?!"TI xt--------------••-••••-• :. U ----•--•--•-•----••----••--•-•----•••=----------•--.....•...............••-------•-••........-••-•----....--•-•---•----•---•--•-------•---••-•-•--•=---...••-•--•---...........---------••--------•----. UW --•••------------••-•-•--...----••-•-••••--•--•--••-•-••-••----••-••-•-••----•-••-----•--••••--•••-----••-•-••---------•---------•--------•---••---•-----•-----••-•-----•......•-••••......---•••-•-•-- 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 TIT_1Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued y thbo'a d of health. Signe �!J• ��� _ •--•-----------------------•----••-•-••----•..---•- ................................ Application Approved By...... �' 'fir ... /+ ........................................ Date Application Disapproved for the followingg/seasons:://---•-•••-•--•----•--•------•------••----------------••-•--------------•-•••----•--•-•-••--•--••••-•--•---•-- �( Date uPermit No....••--- •.L= •------- ..--------••----------•--- Issued.................................... .................. Date $ b THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............�!'................OF......... .... ..................... (9rdifiratr of Tomptianrr THIS I T CER Y. That the Individual Sewage Disposal System constructed (V) or Repaired ( ) �� � x at................� ...-•-----� ....---•----•-- alley-•�_ /---•-•----� .....--------------...-----•---..._..._..-- has been installed in accordance with the provisions of Tjj� ej The State Sanitary Code as described in the application for Disposal Works Construction Permit No____________________ ____________________ dated--------------------------...................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONST UED AS A GUARANTEE THAT THE SYSTEM WIL FU TION SATISFACTORY. / DATE....l� � .._.... Inspector ...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT �4 ............. :.........OF....._.... ......./ ..........--................ No....../.Lrd.... FEE........................ ��.,,4 �i��o��tlrrk� #rtion rrnti� Permission s hereb granted.....................y....... ; to Construct or pat ( ) a �datiti�lal e� ispos hi i/ a No............................................................................................................................... ................................................................ _ Street as shown on the application for Disposal Works Construction e .____..___ -----•-•---•••................. �L!;' ..%� DATE.................. = '/----------•---- ---- Board of Health FORM-1255 HOBBS & WARREN. INC.. PUBLISHERS No.. - -- THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH ..........OF.......... ...��.lY �'�-- ..0c...._.. Appliration for Uhiposal Works Tonstrurtiun thruti# Application is hereby made for a Permit to Construct AA) or Repair ( ) an Individual Sewage Disposal system r�/fit -- �=�' I .... • ice'�' .._..._. .... ........ �-�� V_% I J' /- Locatio/n-- ddress /or Lot No Owner Addr ss ,q �, .....................•-•---•-•---------..................-•--•- -•--. .! _ '�..:_ 1�✓Nf /!T/ F�._o................-•--•----------.. p� Installer Address U Type of Building ,/�I �_Size Lot/ -2! ��._.._..Sq. f et �., Dwelling—No. of Bedrooms......... '...........................Expansion Attic x 'Y� Garbage Grinder VV6 aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .....---=--------------••---•----------......-•-------.---•--------------------------------•-.........._------ t...... .:._.. W Design Flow................. ... ..............gallons per person per day. Total daily flow............. J�)..................gallons. WSeptic Tank—Liquid capacity/D?Q.gallons Length...°-4_..___ Width....16....... Diameter................ Depth............ xDisposal Trench—No. .................... Width__..____ r..... Total Length............o.._.__.Total leaching area....................sq. ft. Seepage Pit No.......L___...... Diameter....... Depth elow inlet.... Total leaching area. 0.�_....sq. ft. Z Other Distribution box Dosin ank ( _ Percolation Test Results Performed b .. 4. .:i �C''..__ : :.................. �� � a Y f....-•- Date Q: Test Pit No. 1..... -----mmutes per inch Depth of Test Pit.................... Depth to ground waterA��..... u j fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .............. -I ....._.... O Description of Soil............. - t�� � �i� � ............. . x --•---,--------•------------------------------------------••-•-------•-•--•--•-----•-------•---------•-•---•-----•••-•-----•-----------._....-----------..._.._.._------ U Nature of Repairs or Alterations—Answer when applicable.................................................................................._._........._. -•-------------------------------------•---•------•-----••--•--.....---------...._............-•--•--------...-----------------•---------....----------•--•---------•-•----........---..._.......••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT 1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b 'en issued b t boa of health. .PC9 Date Application Approved By................. " Date Application Disapproved for the following reasons-----------------------------------•-------------------•------•---------------...---------------...------------. ....................•---------------------------......•-------•---•-------------••-----.......------...-------•--....---------------•---•-•••------------.....------..:=..--------------------•--•------ Date Permit No.............. __-_... Issued..... - ....................................... Date No Fim" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .7.7..---......OF...........Z:a_.K ri s-...--.-G..�.�e... Appliration for Disposal Marks Tonstrurtion ramit Application is hereby made for a Permit to Construct A or Repair ( ) an Individual Sewage Disposal Syst — � f� 4.,k / r��L �o 7� f1__ V /� f..... » - -......... ..... ........................................ .........._ ......--..• •... -•- Locatio - dress •or Lot No. /1 \J /� , ppl:o ep 77 a d' .< e �'l ors f/r 'eS v h - - -----.••••.. ........... ....... .»». Owner Addr s ............... `...�B C. s„t... --•--••-•---------------------------------- .,;..t..a r�.................................... S Installer Address V'L/d 0 q Type of Building Size Lot -V----------------------S . feet U Dwelling—No. of Bedrooms...........................................Expansion Attic MC Garbage Grinder NO Other—Type of Building No. of persons............................ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) d Other fixtur --------------•----... y`�, W Design Flow..................•............ ........._.gallons per person )er dray. Total daily dailyflow............................................ WSeptic Tank—Liquid capacity .���gallons Length. `r.... Width....6._..... Diameter................ Depth............ x Disposal Trench—N�. .................... Widt�..�.yt..... Total Length_........... -r.---- Total leaching area........./-....sq. ft. Seepage Pit No..................... Diameter................. Depth elow inlet....9............ Total leaching area..?�............sq. ft. Z Other Distribution box Dosing�ank � X i� e ova Axf�� /y l a Percolation Test Results Performed by........................ Date----------,--..--...1----�..---. Test Pit No. 1...... .....minutes per inch Depth of Test Pit___.__.��._....... Depth to ground water ... .. GTI Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -- --.---- Descr>ption o �So>l_..q!� ------. :.............. ---------------------•- ... .� 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 TITLE 5 of the State Sanitar Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued b th- �be,boo�-- of health. ................................ - ..�... / ate A lication Approved B PP PP By..... F ,.....•. = � �-------- ..•2 . ••-•-- D t Application Disapproved for the following reasons------------- ----•-------------------------------•-----------....--------------------•-•---•-•-•-••---•......._. ..............................................................................................-.........I............................................................................................... Date PermitNo....... ........•---................................. Issued------....................................- ....... t Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH "' ............. .......... ....:.:.........O F.......... . .....:..............................................r............. %T�rrtif iratr of Tttmpliaurr I T CERTIFY That he Individual Sewage Disposal System constructed '�^or Repaired IT;S... t -S g P---- 5------ ) P by :. ---�,.�... �..... -` G / nrlaller t at ..' / has been installed in accordance with the provisions of TI 5 of The State Sanitary Code.as d scrib d in the application for Disposal Works Construction Permit No_-....--------- -------- dated_-_../4',.�_"_-��............ THE ISSUANCE OF THIS CERTIFICATE SHALL-NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIQ SATISFACTORY. DATE.......... � =__ Inspector--• - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �d 9 ................� 0F h..... ..........i 1 �X........---•--......_...........-----........ , N......... ....�.. FEE........................ Maps ork its i 'wrt rrmi# Permtssion'hereby granted _._ ... ............... to Constru ( ,�( or Repair ( ) an aduual Sewlag� p`o Sys at No..»" /�/� �G�/. Z_."�-------- <..... fZ! b.(�-. fir' bF'� ..... ................ Street as shown on the application for Disposal Works Construction PermC.it'hYo........ ........... ated..lf... ..... .......................... D — _ Board of ealth DATE--------•-------••--�•-•-•-- ------•------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS w �I s s h o w ' 0 ?.7 � . e. Pl o y .3Z 3 73 u � � r .�o� s T r2 v� 7- 1 � � � ���v v��� �y 90.- 0 , C w J'cti zv f G 1 '`rya o �' d ,t i I 4 /�/O 6,q Yt3C e V6 kkI tr, 4j v .� f 0 i ti44 27 v /k-o» ;nc-n l Cps, isL�- c3 A � 1AV / e� /fit �aj� � .� ,�1/l t� f S�Lr3•t e' L /YJ �tr zlea —� 49 4 e / �o r � O 100, PLAN ofr LAND a 114 q• �r G���/7"��' v�rv� MASS-* 0 47- F � � Of OWIaE� BY OF il ' _ a i yw c "� t RANK s c�� KY ' FRANK CONERY 5 TRENTON St corvEWr 4 +�►ts,3 q � MYAaNtg. PUS. 0�1 &L 6232 O 9� E`&�6 r`f�'��'�� +c6�cnrutaaa rJofw A LAND dUfft aow � cwC1�7 ��y00 i, sraNaiv'61 ` 4�0 su s SCALE FT. 1191-�1&0 w f -5 I-IQ v/ e- r-,r 0A' / �>I/a !��ee ��,J„, -1 4.AL )7,f f G.�.,�••? �L,a�� � �� � !/�d f''P G'>7 7 iL'.=J p GC trGl 'J`� f T'�4+�G ��7 101 73 Ile -> ��SI �7N ��'oiyS Ti�.vC Tra�/�. O�" '• r ��� _' �•( b,, `�� v �Lyr W ♦•.•.� ae' .� I/.r•�"i�'ei�+Miw+ e' } �,�x,7 � 4' n�� / e Vc O FRANK, ' ,~„r• r`";000 2SWLOAWO Y 1 COfCERY ui• { �-CONERX *Nc. 6232�� t\ No. 65736O ' r s " C SU FSs1 FW K CONERY •S•T�.* ' • l �r ' f . Q 7. wI •` - - e�..�,'��' -t''il,,; -• l f�t!t��.°"�7I P'e� rt ��.►, 1 ' .., Ii. / i , t ' ' � •• .. y •2'-6 2! /•+� z .S B.s' ` + I ..a `� � �� , . . r r•� � � .,r 4 J� lad { �}j} - •"�a • 1 , �'� t ' 1, - • 4•`;•.d ,t, •.^ 3-.,y'� y #.-�?' � i } -`� ... .._._...'r -f-". ..L r .-. .' `�.:'' -t "' _ - •. - J� .. �r• . •. ham.. '• `''"' t[...