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Home My WebLink About0357 WHITE OAK TRAIL - Health 357 'White Oak Trail Centerville A= 192-238 ESMEAD No.2453LOR UPC 12534 smaad.com • Made In USA MUMMDiM uc um SFI �� CERTiRED SOURCWG pROGM WWALWww"MAM 1 No. `` V�/ Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliLAtion for Misposal 6pBtem ConstrUttlon 3pPrmit aL Q v Application for a Permit to Construct( ) Repair(/` Upgrade( ) Abandon( ) ❑Complete System .individual Components M Location Address or Lot No _iY7 toh 1k AV „_ a' Owner's Name,Address,and Tel.No.9j 9g-6S'3•- Assessor's Map/Parcel)Qa 3$ 91�1� -'� Rose ��1/.sat� �9W;Idw«�Q s+. Installer's Name,Address,and Tel.No. Designer Name,Address,and Tel.No. g^/b# Z�* -13 p 9 Type of Building: j� I Dwelling No.of Bedrooms '" Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ZI 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.d A 1 611 ;2 Description of Soil �Ni wen Natured of Repairs or Alterations(Answer when applicable) : p . 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 Environme a and o place the system in operation until a Certificate of Compliance has been issued by this Board of Signed Date Application Approved by r Date 2t Application Disapproved by Date for the following reasons Permit No. �� Date Issued ?��( ' S No. G � V ( Fee t i THE COMMONWEALTH OF MASSACHUSETTS Enteredin.computer: tom/ PUBLIC HEALTH-DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plication for Bisposal *p$tem� CDnstrUction Permit i r �a 2(2 ) Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) Complete System iP Individual Components Location Address or Lot Noa "7 A I k, a k�at� Owner's Name,address,and Tel.No.q��-��3. �j�9G1 act f �' ta�'tcJ�'lr�cc3v c45�. Assessor's Map/Parcel��a a�$ �Aot),� u�(�- dr.9i i A ,ta fBfSt"! Installer's Name,Address,and Tel.No. —h Designer's Name,Address,and Tel.No. 4k Type of Building: � t ` Dwelling No.of Bedrooms t'v� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ,f Design Flow(min.required) IV IA— gpd Design flow provided / gpd Plan Date < Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S.d X Sl�I`fi �`'•� Description of Soil y Nature of Repairs or Alterations(Answer when applicable) T IQ,IOIL P-0 ��l•�'�1�C -t a Ni � t,t no f.,r}� t _ I4IU I��X ��o__l? �!-ak. �> � > e_Q_ 1C�5�-:►� � � ��,e r ; r�� S _j j Date last inspected: Vf - .- 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 :.bah_y,w' '.- �•- �... Compliance has been issued by this Board of Health. Signed �'� _ � Date Application Approved by / _ski''' Date ?i/ ,t! Application Disapproved by C Gam' Date C for the following reasons Permit No. Date Issued t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS.IS TO CERTIF't,that the On-site Sewage Disposal system Constructed( ) Repaired(.Ile) Upgraded( ) Abandoned( )_by n S41 r, u J",Jy) x, f r. at� } ,x 7 lA G",+t ,�,�,� , ��,-1 410;j le has been constructed in accordance with the provisions off,Ti/tley5 and the for Disposal System Construction Permit No. �1��dated Z J Zy Z I Installer I&f Designer 1V1,4 l a n/. L' n i u 1 r � P / pY S/ #bedrooms A) A, Approved design flow 1f/ A i gpd The issuance of this permit shall not be construed as a guarantee that the system wdZl n tion as designee. D Date 3j��L 1� Inspector _ /�,� �+ V - . No ..2,io7,.I ^--DJ { Fee A D - (� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Bisposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(✓) Upgrade( ) Abandon( ) - System located at�� lc.1�,�� t�C=t_(� ,�,�s_ ,F✓n 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. r r >° Provided:Construction must be completed within three years of the date of this permit. Date '"7�l-a (.!'ra 1 Approved by _ _; �._ •t �r , r TOWN OF BARNSTABLE LOCATION Z�`] OR-.�� ac.�f LSEWAGE# 1-0�'1 VILLAGE (�__L-%JI ,!-_-- _ tJPZ.0 ASSESSOR'S MAP&PARCEL �1 Z-23 F INSTALLER'S NAME&PHONE NO. -C• L S-OT_'7Z1 - 93 SEPTIC TANK CAPACITY I SGLo E•..4d— 4 Laz LEACHING FACILITY: (type) NO.OF BEDROOMS 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 L 3 S� ;A-�e 064 -� I A O � 33 . • I tll On!NIS,Insu nice Coverage Provided), NFor delivery information visit our�Yebsite ak-3vww.usps.como o 1 A L U Ln tD Postage $ fl! Certified Fee \ O Retum.Recelpt Fee �Post p (Endorsement Required) �� ere \ d y Restricted Delivery Fee �' 3 a (Endorsement Required) p Total Postage&Fees I$ 179 ti Irene L Jackson TR� o % Leland H. Jackson, Jr White Oak Nominee Trust 69 Wildwood Street wzc w,-s t°^o 7 Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiei;"e p ■ A record of delivery kep%by the Postal Service for two years Important Reminders: ii Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. i For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 9 SECTIONSENDER: COMPLETE THIS SECTION COMPLETETHIS ON DELIVERY o Complete items 1,2,and 3.Also complete A. Signa re item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X A.�f — ,��r J � ❑Addressee so that we can return the card to you. B.,Received by(Printed Name) C. Dat 'of Delive/y ■ Attach this card to the back of the mailpiece, �� <? or on the front if space permits. D. Is delivery address different from item 1 Ej Yes' 1. Article Addressed to: If YES;eriter-delivery address below: ❑No Irene L�_Jackson TR i @ % Leland H. Jackson, Jr ;S�,� White Oak Nominee Trust 3. $ `Lc`e,Type.cjliw / 69 Wildwood Street I Certified Mail--�❑Express Mail Wilmington, MA 01887 ❑Registered URetum Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2i;:,Article Number . (Transfer from service label) 7 012 1010 0 0 0 0° 2'8 5 0� 7565 PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 I , I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • I � i Town of Barnstable Public Health Division i 200 Main Street i r Hyannis, MA 02601 TOWN OF BARNSTABLE LOCATION S W 009e aA/i.L1J SEWAGE # 2011- 0!3a, VI�LAGE C2bjj.n � ASSESSOR'S MAP & LOT oZ�� INSTALLER'S NAME&PHONE NO. 36,�—yqLa 6 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) + 0~ 3 lrA (size) NO. OF BEDROOMS BUILDER OR OWNER yy PERMPTDATE: �I i�I1 3 COMPLIANCE DATE: "31�• 0 1 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 - PW r�o 04 nn � R' -c 9A 6 „ W 4% JI JI 0% -33=7" y 5 3 .-°a " Li 5 Ll 3' Town of Barnstable Inspectional Services Department ` °A TABLE MASS.A M Public Health Division y 039. '°rFo MAC a 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 8319 January 12, 2021 JACKSON, IRENE L TR 69 WILDWOOD STREET WILMINGTON, MA 01887 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 357 White Oak Trail, Centerville, MA was inspected on 12/28/2020, by Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The septic tank is leaking. Need to replace or repair the septic tank. • Note: Replacement may be the only option as the tank was previously repaired in 2013 and is leaking again. You are ordered to repair or replace the septic system within one year (1) year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas cKean, Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\357 White Oak Trail Centerville.doc IKE tj Town of Barnstable 39. g Inspectional Services Department p Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CIiO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems'' (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER fA 1 k;h -9� k ok l �� m;7 Repair deadline: UPS G �'Ovl ,j tie 4c A Ppto J ,,, 2,915 f,,qd o jecX,A) Clio?;/?, Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts 19�_ a.38 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •� 357 White Oak Trail Property Address Jackson ` Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information 614 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 z 12/28/20 Inspe a 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t; 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown 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: ❑ 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: 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): The septic tank appears to be structurally unsound due to substantial exfiltration. There is 1" of effluent in the tank at this time and in my best professional judgement it is not due to evaporation and presumed to be leaking. The D-box is holding water at the appropiate level at this time. Per BOH record this tank was found to be leaking in the past and was repaired in 2013 t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner s Name information is required for every Centerville MA 02632 12/28/20 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 ❑ 9 P 9 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.7/26/2018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown 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 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown 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 cesspool is less than 6" below invert or available volume is less than Y2 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. ❑ ® 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a•v 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owners Name information is required for every Centerville MA 02632 12/28/20 page. CityrTown State Zip Code Date of Inspection D. System Information 1. 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 Description: 3 bedroom plan and permit on file at BOH Number of current residents: 0 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2018 20,000 gallons used, 2019 2,000 gallons used per COMM Water District water meter readings Sump pump? ❑ Yes ® No Last date of occupancy: 2013 per owner Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �. ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown 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: No recent pumping per owner 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 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown 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: 1986 per BOH record, new d-box 2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >10 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass El polyethylene ❑ other(explain) H-10 tank appears to be leaking with 1"of effluent in tank at this time If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1250g Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �. (P Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown 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 Commonwealth of Massachusetts ,t? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 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.): H-10 D-box is 18" below grade, cover raised to 6", box is in very good condition, effluent level at the bottom of the outlet invert t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown 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* J 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: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 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 1" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. Cityrrown 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.): Leach pits were video inspected and are dry at this time, no indication of past hydraulic failure, no adverse conditions observed 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 off, Commonwealth of Massachusetts �. 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts �d r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -o u 357 White Oak Trail Property Address Jackson Owner Owner's Name ' information is required for every Centerville MA 02632 12/28/20 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.7/26120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 12/14/2020 Assessing As-Built Cards TOWN OnF-=ABLE LOCATION J�� W , {T SEWAGE�i `eZ01�-0'2a, VMLAGE C2nnT�h; ASSESSOR'S MAP&LOT a13�4' INSTALLER'S NAME&PHONE NO. a SEPTIC TANK CAPACITY LEACHING FACILITY:(type) + (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 'J 1)41 IS COMPLIANCE DATE: '3J;LaI 1� 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 q- ► a9=s'; 3 4 4t' IL 5 �IT! 3 a 33=-2 y - 5 w3. https://www.townofbarnstable.usiDepartments/Assessing/Property_Values/HMdisplay.asp?mappar=192238&seq=2 1/2 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 357 White Oak Trail Property Address Jackson Owner Owner's Name information is required for every Centerville MA 02632 12/28/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >14' 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: 1986 NGW 14'Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 1986 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at70'msl and nearby surface water at 32'msl You must describe how you established the high ground water elevation: See above 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 �d (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 357 White Oak Trail Property Address Jackson Owner Owners Name information is required for every Centerville MA 02632 12/28/20 page. City(rown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 J Fee v V No. C� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplicatlon for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade(/Abandon( ) ❑Complete System ❑Individual Components Location dd ss Qr Lo o. "� O Owner's Name,Address,and Tel.No. Assessor's Map/Pa�rce�.l7 " Installer's Name,Address,and Tel.No. 36,;L- y 9 yd Designer's Name,iddress,and Tel.No. A Type of Building: Dwelling No.of Bedrooms o'Z Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)() gpd Design flow provided 330 gpd Plan Date Number of sheets Revision Date V Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��l� !' Ail, �i�SL11►Q .4 � ) U i 4 I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. j e Date 1 l Application Approved by Date Application Disapproved Date for the following reasons Permit No. lif�l"� Z Date Issued i I Gov - t.. No. ZO �' � - FeeA� Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for 33isposal .6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(V) Abandon( ) ❑Complete System ❑Individual Components Location I& ssor Lot No. 3 5-7 � �� O Owner's Name,Address,and Tel.No. Assessor's Map/Parcel CQ►-�+ Installer's Name,Address,and Tel.No. 36,;�- 9 9 q&; Designer's Name,iddress,and Tel.No. O, &Y&6� Type of Building: Dwelling No.of Bedrooms oZ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No:'of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) O gpd Design flow provided 3 3d gpd Plan E Date Number of sheets Revision Date Title I Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 riot to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. 1 Date Application Approved by Date Application Disapproved Date for the following reasons i I - Permit No. / 72 Z Date Issued --------- THE COMMONWEALTH OF MASSACHUSETTS �-- BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at 35? LUM-1 E ofI1L, 7Z CE.tjT V��E has been constructed in accordance r e �� with the provisions of Title 5 and the for Disposal System Construction Permit NoZo13-082- dated 3/jjN_4Z�Q 1 ts Installer n V p ; Y . Designer #bedrooms Approved design flow god The issuance of this permit shall not be construed as a guarantee that the system,w'ill function-as.designed. _ Date / Inspector '� No. L,"' 2— Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *p8tem Construction Permit Permission is hereby granted to Construct( ) Repair( V� Upgrade( ) Abandon( ) System located at 35� w +%-T—c pA r— -7(141 LL <2€'N 77s—"/`.--L 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 3//y f Zy t Approved by �-- I Town of Barnstable Barnstable .� Regulatory Services Department j"�'caC j IAItNSTABM ' MASS. Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7012 1010 0000 2850 7565 April 1, 2013 Irene L Jackson TR % Leland H Jackson, Jr White Oak Nominee Trust 69 Wildwood Street Wilmington, MA 01887 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located at.357 White Oak Trail, Centerville, MA was last inspected on 3/10/2013, by Michael O'Loughlin, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Septic tank and distribution box have to be replaced. You are ordered to repair or replace the septic system components within Two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH s cKean, R.S., CH Agent of the Board of Health i Septic\cnditionally passed\357 White Oak Trail Cent Mar.2013 i k\- . 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: 1 . only the tab key to move your MICHAEL O'LOUGHLIN cursor-do not Name of Inspector use the return key. Company Name 714 MAIN STREET Company Address YARMOUTH PORT MA 02675 'e"01 City/Town. State Zip Code 508-362-4942 577 Telephone Number License Number „mar B. Certification 5 ... rM I certify that I have personally inspected the sewage disposal system at this address and thai'lthe , information reported below is true, accurate and complete as of the time of the inspection. T_k inspection was performed based on my training and experience in the proper function and m?intenancfiof od'bite sewage disposal systems. I am a DEP approved system inspector pursuant to Sectio ,t5.3,4M Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/12/13 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 31 ,1`� � o � t5ins•11/10 Title 5 Official Inspec n rm.Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ® ND (Explain below): PERCAST CONCRETE TANK IS LEAKING , NEEDS TO BE REPAIRED OR REPLACED. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 �. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,•''y 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ® broken pipe(s)are replaced ❑ Y ❑ N ® ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ® ND (Explain below): D- BOX NEEDS TO RAISED AS TO CREATE A POSITIVE PITCH TO LEACHING PITS AND CHECK PIPING TO PITS. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2012/ 22,000 GALS. 2011 / 117,000 GALS. 2010/ 152,000 GALS. Sump pump? ❑ Yes ® No Last date of occupancy: UNKNOWN Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: BARNSTABLE B.O.H. LAST TIME PUMPED 4/26/10 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 10/1/86 BARNSTABLE B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'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 INLET PIPE HAS A POSITIVE PITCH UP INTO TANK. Septic Tank(locate on site plan): 1' + Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) SEPTIC TANK IS LEAKING EFFUENT, LEVEL IS 10" BELOW OUTLET PIPE. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,250 GALS. Sludge depth: 2„ t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632. 3/10/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 2" 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 'How were dimensions determined? TAPE MEASURE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): LEAK MUST BE REPAIRED OR TANK REPLACED. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 357 WHITE OAK TRAIL Property Address LELANDJACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 3"-4" 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 NEEDS TO BE REPLACED AND RAISED TO CREATE A POSITIVE PITCH TOO EXISTING LEACHING PITS AND EQUAL FLOW. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6'x4' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): APEARS TO BE IN GOOD WORKING NO SIGNS OF HYDRAULIC FAILURE. BOTH PITS WERE EMPTY,WITH A STAIN APPROXIMATELY 18"OFF BOTTOM OF PIT. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes. ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 •� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A N y -41" O O 5 3 � 5 `f 3/ t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 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 high ground water: 8+ 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: 6/13/86 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 9 you established the high round water elevation: Y g TEST HOLE ENCOUNTERED NO WATER 14.5' BELOW GRADE , BOTTOM PIT IS 6' BELOW GRADE. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 357 WHITE OAK TRAIL Property Address LELAND JACKSON Owner Owner's Name information is required for BARNSTABLE MA 02632 3/10/13 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file a t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � � iv See) - �� ASSESSORS NEAP NO: s No.......................S PARCEL Na.-_ F $..........................._. THE C6MMONWEALTH OF MASSAC 16SETT8 BOARD OF HEALTH ............. ........................O F..........................................0_-.------....-----•---......................... Appliratiun for Uiupuuttl Morks Cnunitrur#inn ramit Application is'..,hereby made for a Permit to Construct V, or Repair ( ) an Individual Sewage Disposal System at: . ......... s.7..... 1 _�. .. r.�►:1................ ..•---....------...........__..--------_.._.. ......................._.................. / Location-Address or Lot No. ........... 67:z:.wo6Vln4--fir .. il?�. t. ...f?��1........... Owner Address W Installer Address Type of Building Size Lot_..........................Sq. feet � A/- Vwelling—No. oBerooms..... ................................... p Garbage Grinder (X) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- . W Design Flow.......... ... .5..................gallons per person per day. Total daily flow........... 3..o...................gallons. WSeptic Tank—Liquid capacity. ...gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width...I................ Total Length.................... Total leaching area.................... ft. Seepage Pit No.....�.............. Diameter.__... ._..__..... Depth below inlet......._..._..-_. Total leaching area. $S_.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) PercolationTest Results Performed by.......................................................................... Date----------------------........................................ �a Test Pit No. 1___z......".minutes per inch Depth of Test Pit...... Depth to ground water....... ----------. G=. Test Pit No. 2___.! ....minutes per inch Depth of Test Pit.......0:.e_2.. Depth to ground water........................ --------------------------------------------------•-------•-------•--------•-••--•--------........................................................... Description of Soil..-----...E�;� 4�a D ft_��__ ...-.. . S-..vl .........L C-!..S..---- U5�t M V .e.� `.. ...................... .................................................. W ------------------- -----------------------•-------------------------------------------------------------------------------------- -----=-------------------•--------•-•-----------------------.-------- UNature 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'ITLEE of the State Sanitary Code The undersigned further agrees not to place the system in u til a Certifi t of Compliance has been i sued by the board of heal h. Signed �G!y -- --------------------------------- ' Dat Iration Plication Approved By. .............. .....---.. .. .._. ..-• G' f 3 .. D e Application Disapproved for the following rea n -------------------------------•-----•--------------.....----------------------------------..._................ -------•--------------------•------........-•--•--•-------------------------------................-•----•-•-----------.....__._....--•------•--------•---------------------••-----•--•-------------•--- Date PermitNo......................................................... Issued-....................................................... Date ASSESSOR'S MAP N0� e ARCEL �S b lt°) C A T ION S W A G E PERMIT N0. VILLAGE INSTALL R'S NAME i ADDRESS I U i L Di R OR OWNER D'"ATE PERMIT ISSUED DAT E COMPLIANCE ISSUED l_ ,� i�) J r :+ a ��`I �� : > - - � � ;,1� � .��► .�� • I`�ate. r e FEE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ..................:........................O F........................................------------...................................._. Appliration for Disposal Works Tontrnr#ion rermit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ............ ......................--........................................................ --- ovation-Address c3 S 417 G7 .•06vr 5 ►r d% W Owner Address •.................... - ........... .... ......--......... ._.. ... pq Installer Address Q Type of Building Size Lot............................Sq. feet U g— 3 ...................Expansion Attic ( ! Garbage Grinder (A) f-1 6'"'1�wellin No. of Bedrooms......................... aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ..------•---------------------------•---........-----......---------------------------•-----•-----....... ------------ Design Flow....... .�..`�_-•r .. 3 C? W M1 gallons per person per day. Total daily flow..._.......-�..............................gallons. WSeptic Tank—Liquid-capacity.!e..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width... Total Length.............. Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...... Depth below inlet................. Total leaching area: A'.._....sq. ft, Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by----•--•-••------------------=----------•-----••--...__......----•----•-_. Date----•---------•-•-•---.........._---... Test Pit No. 1....6- .a".minutes per.inch Depth of Test Pit...... '-:... Depth to ground water.......' .......... 44 Test Pit No. 2..... ....minutes per inch Depth. of Test Pit....... Depth to ground water..................... P4 -tiv--l-�--------••-•---•...................................••-------•--•-- ------------r-.. •' ------.D Description of Soil----....... .-•----...KVi .Ct` ± t._ ... ------------------.-.-.-.-.-.-.-.-.-.-_-.-.----• >A04b '- CO6rISi�-U -----•----••..................•---------- --.... - -------... •--• -------•...---------- .. •..... .................................................. UNature 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 TIT11' 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in ja ration u it a Certificate of Compliance has been i ued by the board of heal h. .Signed--- ---:'. �$ ................. •--•--•- at Plication Approved By....................................---•....................- .............. - --•-..... , .......... � - Application Disapproved for the following real n :------•-----•.............................•----•....---------.........-----------•-•----------•----••----•---- .........................•-----•-----•------------------••-------•------•-----...._...------........-----••••----•------•----...----------•------........------•---.....-------•---•--------•-•-•-----. Date PermitNo......................................................._ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............� . NS....................................... (Entif irate of Tontplianrr THIS IS TO CERTIFY That t_he_Individu Sewage Disposal System constructed ( or Repaired ( ) -------------- s - i by_.... - -"' ---------- t�c'rl Lt. _�.%................. ...... .... :...- - Installer xx Ii has been installed in accordance with the provisions of TITLEE/5 o State Sanitary Code as sc ibed,�'n the application for Disposal Works Construction Permit INTO---------- ___. 1 _.. dated._ , l�l.. '......... THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................:.:� .� .................................. I Inspector........ .................................................... �7 `a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH flispoottl Ends Tono#rurtion amit �a5r r {( NtitzP C, Permission is hereby granted. ................1----1.................._-----•.........-- ....................................................... to Construct ()Z) or Repair ( ) an Individual Sewage Disposal System/ t at No.. �-r fit ! Eti-►rC c�1L t 'T ��..��10.--•-----..._ --•---.... ---......_.... ----•_ ----... Street f .as shown on the application for Disposal Works Construction Permit No.$6!......... Dated----------G {( I 3 ► ............................................ s........ .._...._ _ rd of Health DATE.....................-/U-----•----�.........�6•-------------- FORM 1255 A. M. SULKIN, INC., BOSTON�. A k.: 3 61 F y a S 11297 o 4- 6 sk I A IZyj 28,627 sf ' L C c # 3? 371 Z 7 16,958 No J 372 , µ � n ^\61 } E� L J y O � D�• 1 i LAN F LAND m D A T E S C A L E DRAWN CHECKED A O A N A MAR. Z �� /98 Z o ---- �� LOTS 61 , 61- F, 76 RtCCRD PI. AN S � .� n..� REVISIONS 4 BOo 3 4 n., E '76 ` U� Description By Ern �+, BARN STABLECENTERVILLE) . y — OWNER : LELAND H. & IRENE L. JACKSON — 672 WOBURN STREET WILMINGTON, MASS. K . J . MILLER CO . , Civil Engineers & Land Surveyc "" 106 WEST STREET , WILM., r� EXISTING GRADE_ _ _ , _ PROPOSED GRADE PLAN KEY AND SPECIFICATIONS ; DESIGN DATA: LEACHING PITS PERCOLATION TEST RESULTS : i 2 CONCRETE DISTRIBUTION BOAC WITH A MINIMUM l .' RATE_MIN. /INCH. , DATE S/° fL, BY 1�14"'W T+ 6" SUMP. OUTLET INVERT ELEVATIONS TO BE 2 . RATE—MIN, /INCR. , DATE_._, , BY EQUAL. REMARKS : PAr,.: C3 .' 4 " PVC PLASTIC PIPE , SCHEDULE 40 GROUND WATER DETERMINATION : MINIMUM SLOPE '/-" PER FOOT. CC FSS coVr F- a,- 6RAVE- -a N LOCATION , 24 , I7� GALLON REINFORCED CONCRETE SEPTIC TANK - _ `� _ CAPACITY I1.,7 CU. FT. 1 (Lio i,.. e-r �r<. lei. r Q 4 " P 4 . CAST IRON PIP$ WITH LEADED AND CAULKED x 2 JOINTS . SLOPE j4` PER FOOT. ESTIMATED SEWAGE FLOW: 4" fL� }a �� SANITARY�;30 G .P. D, .l"_� r OTHER gip" G . P, D. GENERAL NOTES t TOTAL ':„ G. P , D. 1 . INSTALLATION AND COMPONENTS OF THIS PRIMARY TREATMENT-SEPTIC TAFK DISPOSAL SYSTEM TO BE IN ACCORDANCE WITH TITLE V. - CAPACITY ---GAL-. � r,7 CU. FT. PROFILE BENCH MARK _ = - REMARKs FLOW LINE SCALES : VERT. I IN.= 4 FT HOR. I IN.= 20 FT 2 . DESIGNING ENGINEER TO CERTIFY CONSTRUCTION AND ELEVATIONS IN ACCORDANCE WITH APPROVED SECONDARY TREATMENT-SUBIRRIGATION PLANS . LEACHING PITS_NO . DIAM.0L DEPTH. 3 . DISPOSAL SYSTEM DESIGNED FOR SANITARY WASTE ONLY . BOTTOM AREA CT1'( 50)` x t.O S/F 7 4 . SEPTIC TANK SOLIDS TO BE REMOVED ANNUALLY . SIDE AREA '' i(-;x,t ' �- 5 . ALL LOAM, SUBSOIL AND -DEBRIS , DIRECTLY TOTAL ABSORBTION AREA PROVIDED UNDERLYING THE DISPOSAL FIELD , TO BE ABSORBTION AREA REQUIRED REMOVED AND REPLACED WITH PROCESSED CONCRETE SAND TO ELEVATION IF REQUIRED . P - 5649 REINFORCED CONCRETE SOIL CLASSIFICATION -LA } PRECAST COVER FINISH GRADE 2 % SLOPE kd, --� =-• ate' c" VUF j I SA N-D SLIM!L8u - .� l.�e / \ .► •. �- t•�.' 'j;�i'•�'a ,�. �•� 4n- 3/8" 30" �tNP 2� 0,� PEAS TONE ...�y „r 1-. 0° _ e ` r '\ �•�-�- ----- - • . AFL �l. V�� 'l�( $l'N .... R �`---''.-� . � 8„ CONCRETE 3/4 - 1 BLOCKS ON SIDE 3/4 -I ��" ��" a�� F�k4, I j' CLEAN CLEAN �tv At k i i lam. Lfzac�� r r� STONE STONE ci .� �� e EXCAVATION LIMIT - L'e� eg �0 6 ---2 e, ► TYP. LEACH PIT SECTION Vie 5-7: 5 z r_. E� NO SCALE T SEWAGE DISPOSAL SY. --- i DATE SCALE DRAWN CHECKI _,-,ilt ED AS SHOWN t LOTS 61 , 61 - F, & 76 REVISIONS ' Date Description By BARNSTABLE , felt r � •�,,,�.`„ of �`q�r • y,. OWNER ' LELAND H. & IRENE L . JACKSON ^� KEFNMETH 1 672 WOBURN STREET „M '-E WILMI NGTON, MASS. LOCATION PLAN K . J . MILLER C 0'. INC. Pr Civil Engineers & land Surveyors 106 WEST STREET , WILN► .- _