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Home My WebLink About0073 WILD GOOSE WAY - Health 73 Wild Goose Way Centerville P A = 167 041 = Omrford, NO. 1521/3 ORA .� 10% No. o (✓I Lf ! Fee �VV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippIication for ]Disposal �6pstem Construction 3permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System If Individual Components Location Address or Lot No.-7 1R JA-4 Owner's Name,Address,and Tel.No. r cy(&c,C `_.Werr S C-t-H Assessor's Map/Parcel -71, W(LI> Gr (>z.®p$6 A*-1 <2��/ Installer's Name,Address,and Tel.No.56247Z-g$-�' Designer's Name,Address,and Tel.No. �a4P€c,�c�L� �Te2Psos�� N/� Type of Building: DwellingNo.of Bedrooms Lot Size s .ft. Garbage Grinder . � q g ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Al gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) M`OL4C& 0—6vx 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. Signed Date Application Approved by - Date Application Disapproved by Date for the following reasons Permit No. j Date Issued J.2 No. 90 Lf H A Fee /VV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS YeS ftpYitation for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(aO Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.-7 3 W(4-) G D osc WA4 Owner's Name,Address,and Tel.No. i Assessor's Map/Parcel ( (011 O L4 -71 W I L1> C-r ODSE L &-1 OjG _ ]C iLt. Installer's Name,Address,and Tel.No.562-q77-Z&'7-7 Designer's Name,Address,and Tel.No. do4 s wc-DF EuZt2Ps� - N/A • ' Type of Building: "I Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) l - i M Date last inspected: p Agreement: i ` 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. o - c Signed Date t•;•> Application Approved by Date _ rl U` f Application Disapproved by Date for the following reasons Permit No. po I L Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded �� ( ) Abandoned( )by C 4GW(DG Q at 7?) w(CD (FZQQSE U AY C'V(Lk C_�_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No o2d1 L(-yam dated f U_(C Installer COGwme L4c_ Designer #bedrooms I( Approved desiin flow f '1 The issuance of thi�pe it shallnot a construed as a guarantee that the system ill, n`ti as des ig ed.(/ /L �! Date Inspector ��,��Al "1/�i ' - ----°-------------------------------------------- -------"--------------------`-------r V v-------1-"- , No. L C '`1 740 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Nsposal 6pstem Construction i3ermlt Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at / 3 w t(,D a c S& WA-,-( �_V(414_ r l 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. i Provided:Construction must be completed within three years of the date of this permit"- \O Date �� 10_f� Approved by III Dec 1014 09:53p p.18 Commonwealth of Massachusetts Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V= r'r 1 73 Wild Goose Way Property Address Janet Smith ° Owner Owners Name = Information is required for every Centerville MA 02632 12-10-14 page. Cityrrown State, Zip Code Date of Inspection t ti.F1 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. Imponard:when A. General Information filling out forms ` on the computer, I use only the tab 1. Inspector key to move your _ cursor-do not James D Sears use the return Name of Inspector key. C y eEnterprises,LLC � Company Name 153 Commercial Street Company Address Mashpee, MA 02649 cftyfrown state zip code 508477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �9— 12-10-14 pectoes Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board d of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design wow 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. I5ina,3113 TWO 5 n Forth Subaufaae DiapOselL•Pape 1 of 17 Dec 10 14 09:54p p.1 g ' s Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name required Information is Centerville MA 02632 12-10-14 required for every page. City/Town State Zip Code Date of rnspet ion B. Certification (cont.) Inspection Summary:Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank-D Box and pit. 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 exf'iltration 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): t5im-3r13 Tga S officW hspechm Fom t Subsurface Sewage Uispoed Sys[om-Page 2 of 17 Dec 1014 09:54p p.20 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owners Name information is required for every Centerville MA 02632 12-10-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System conditionally Passes(cunt.): ❑ 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 ❑ NO(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 ❑ NO (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 16.303(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 ISirts•3l13 THIe 5 Official inspecion Form:subsurface Sewage Disposal System•Page 3 of 17 Dec 1014 09:54p p.21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for every Centerville MA 02632 12-10-14 page. CityfTown 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, perforated 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 is less than 6"below invert or available volume is less than'/?day flow --"/7 t5ins-3113 Title 5 Of►iciel Mrspedion Font StRisuAace Sewage Disposal System•Page 4 OF 17 Dec 10 14 09:55p p 22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is Centerville MA 02632 12-10-14 required for every page. Cityrrown stale Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 9 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 21 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 primate 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 ll 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 ems.3113 Me 5 OfWal tr,spectbn Farm:Subsurface Sewage Disposal System•Page 5 al 17 Dec 10 14 09:56p p.23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owners Name information is required for every Centerville MA 02632 12-10-14 page. City/Town 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? IZ ❑ 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 Solt 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 CM 15.302(5)] D. System Information Residential Fiow Conditions: Number of bedrooms(design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 1 t5ins•3113 Tide 6 O@Idet Impection Form:Subaurfeoe Sewage Disposal System-Page 6 of 17 Dec 10 14 09:56p p•24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for every Centerville MA 02632 12-10-14 page, Ckylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal Tank D Box and Pit. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 214-20,,00 Gal's 2014-20,000 Gal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.fL, 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: 151na•3113 Tide 5 McW kopec ion Form Subsurrom Sewage Diaposel Syabrm-Pape 7 of 17 Dec 10 14 09:57p p 25 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owners Name Information is required for every Centerville MA 02632 12-10-14 page. C4 rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Record: Source of information: 03 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): tsars•3f13 Tide 5 official inspection Form;Subsurface Sewage Disposal system•Page 8 of 17 Dec 10 14 09:57p p 26 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way _ Property Address Janet Smith Owner Owner's Name inforrnrequired is Centerville MA 02632 12-10-14 required for every page. Cityrrown state Zip Code Date of Inspedion D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 1993 Permit # 93 -680 2014 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): nt Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet i n of joints venting,evidence of leakage,etc.): Comments(on condition � g, g ) Pipeing is 4't PVC SCH 40. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 Gal. Precast H-10 Dimensions: Sludge depth: 3" t5ins-3113 hula 5 Omficd k on ram:Subsurface Sowago Disposal Systam•Page 19 of 17 Dec 10 14 09:57p p.27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name Information is Centerville MA 02632 12-10-14 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" 2n Scum thickness Distance from top of scum to top of outlet tee or baffle 12" 16" Distance from bottom of scum to bottom of outlet tee or baffle Asbuilt-Plan-Tape How were dimensions determined? Sludge Jude Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level.Tank and covers at 1' below grade. Inlet tee,outlet baffle. No sign of leakage or over loading Note:Tank to be pumped after inspection. 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 ,Sins•3f 13 Title 5 Official inspeftn Fomc Subsurface Sewage Disposal System'Pepe 10 of 17 Dec 10 14 09:58p p.28 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner owner's Name Information is Centerville MA 02632 12-10-14 required for every page. Cityrrown state Zlp Code Date of Inspectlon D. System Information (cunt.) 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 t5rts•3113 Tfe 5 ol60al bnspecdw Fa=Subsurface Sewep Disposal System-Pape 11 of 17 Dec 10 14 09:58p p.29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for every Centerville MA 02632 12-10-14 page. Ci y[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 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-16"Below Grade w/one Line out Box is new 12-2014 wlcover at 4". Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No` Alarms in working order. ❑ Yes ❑ No' Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located,explain why: Wins-3/13 TWO 5 Of el hapectlon Form:Subsurface Sewage Disposal System•Page 12 of 17 Dec 10 14 09:58p p.30 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name rnfbrrn equire for is Centerville MA 02632 12-10-14 required for every page. Cayfrown State Zip Code Date of Inspedion D. System Information (cont.) Type: ® leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast Pit wl3'stone. Pit and cover at 6"below grade w/1' water Wall's are clean like new. No sign of over loading or solid carry over. 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 Mina.3113 Title 50f vial Inspection Form:SLkswlace Sewage Disposal System-Page 13 of 17 Uec 1 U 14 Uy:byp p.31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is reuire 6or every Centerville MA 02632 12-10-14 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-W13 Title 5 Of del tnepeetlon Fours Subsurface Sewage Dtsposa[System•Page 14 of 17 vec i U 14 L)y:oyp p 32 Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal SysEem Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner owners Nance information is required for every Centerville MA 02632 12-10-14 page. Cityrrown 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 wafter supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A I �. V f C a ❑3 O L t5ins•713 TAIL+5 Olf"Yspad[an Fom StAssface Sewage System•per 15 of l7 uec .i u 114 uy:byp p.33 Commonwealth of Massachusetts Title 5 Official :Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owners Name information is required for every Centerville MA 02632 12-10-14 page. Cityfrown State Zip Code Date of inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t high ground water. 1 feet et 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: 6-8-84 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H.on file at B.O.H.. 6-8-84 no G.W.at 12'+. Bottom of pit at 6'-6"Below Grade. Bottom of pit at 5'-6"above T.H. Depth. Before filing this inspection Report,please see Report Completeness Checklist on next page. MUM.3113 TWe 5 official Inspection Form:Subsuftm Di sat P Sewage spo SyeDeln- age 16 or 17 Dec 10 14 10:00p p.34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for every Centerville MA 02632 12-10-14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5hs-W13 Title 5 pfWal hspadon Forts Subsurlace Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: U n only the tab key /J to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Lu a C-4 " 4/29/2010 c Ins' ector s Signature Date ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board I of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or = has44 design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the Ws* r --•- reportto the appropriate regional office of the DEP. The original should be sent to the system owner andscopies sent to the buyer, if applicable, and the approving authority. lCD— ****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. Tf'\\J1 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Vw.salPage 1 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 _t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 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 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 '/2 day flow t5ins•09/08 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 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. . ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town 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): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 550 ,Sins•01/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 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 ears usage d 2008:10,000 9 ( Y 9 (gP )) 2009:8,000 Detail: 2008:27gpd 2009:22gpd Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron . ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.system vented through the house vents. Septic Tank (locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 2" t5ins•09/08 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 ;M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 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 30" Scum thickness 2" 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 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9c� 73 Wild Goose Way M Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 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 No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.Pit is 6'x6'with 3'of stone all around.Pit was dry at time of inspection.Stain line observed 4' below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 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 �3t+11C AI - 13,((D 6ArA e. A3- I� A a A3- a3 r33- a� 3 AY' 3 ` fay- 3 to t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i . J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 32' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of ground water elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r .J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 73 Wild Goose Way Property Address Janet Smith Owner Owner's Name information is required for Centerville Ma. 02632 4/29/2010 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 7 OF BARNSTABLE LOCA'r!'1N `� W, 1TO7 0TSL (.vA SEWAGE # V'.LAGE t'1 c rV► l� ASSE SOR'S MAP & LOT &7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Soy (� �✓� LEACHING FACILITY: (type) tf"1T— (size) 3 NO.OF BEDROOMS BUILDER OR OWNER SAGk "f' GI A 1 r'e, CA�e,r , PERMTTDATE: 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 f cility) �--�-- Feet Furnished by e � y • �Or� (3UIk A( - /3;(0� A3 6�►�A e. I Qa- as a �3. a3 r33- a� 3 rqy' 31 y r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO EIVED 81'r_ 2 0 2002 TCAW,.. .,VJ I ABLE HEALTH UEPT. TITLE 5 L ( -" (, OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 73 Wild Goose Way Centerville, MA 02632 Owner's Name: Jack&Claire Carter Owner's Address: Date of Inspection: July 29, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 167 Osterville,MA 02655-0049 Parcel: 041 Telephone Number: (508) 862-9400 Lot: 3 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: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: August 3, 2002 The system inspector sh),ub., 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73 Wild Goose Way Centerville, MA Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 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 exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution g p g st bution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73 Wild Goose Way Centerville, MA Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 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. 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 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: 3 i Page 4 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73 Wild Goose Way Centerville, MA Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 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.] No (Yes/No)The system fails. 1 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 System: 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 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 I1 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 73 Wild Goose Way Centerville, MA Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 73 Wild Goose Way Centerville, MA Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2001 -49,000 Qals.; 2000- 63,000 Qals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Puffed in 1998-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Apr. 25, 1994-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Wild Goose Way Centerville, MA Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Approx. 24" Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 I Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Wild Goose Way Centerville, AM Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. There were no signs of solids. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Wild Goose Way Centerville, AM Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'w/3'stone-per design plans 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.): The pit had approximately 2'ofwater on the bottom. The scum line was at the same level There were no signs of failure The bottom to grade was approximately 8. The cover was approximately]'below grade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Wild Goose Way Centerville, MA Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 Map: 167 Parcel: 041 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 3 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. �a 19 a3 33- a7 3 J, 'y- 31 y 10 Y Page 1 I of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 73 Wild Goose Way Centerville, MA Owner: Jack&Claire Carter Date of Inspection: July 29, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40' +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 8. Using the Barnstable topographic map and the Cape Cod Commission water contours maps, the maps were showing approximately 40'+/-to ground water at this site This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 OWN OF BARNSTABLE L T10N Lot � yw,'\41dff* EWAGE # r/ VILLAGE Cpl,%4 tr J'k� ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO. �• - ��o5C4�1 ��? 6 SEPTIC TANK CAPACITY ;s Gf,) S ►IGw t LEACHING FACILITY:(type) L,4_ql,L Yif (size) �100c nI o s NO. OF BEDROOMS '7 PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER ")`71—p3q DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:' " " . VARIANCE GRANTED: Yes No .� J 'Deck 1� u� y/ Fas......�L�1 .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allphrtttiun for Diripuinl Works Towitrurt"tun Frrmit Application is hereby made for a Permit to Construct ( 0/or Repair ( ) an Individual Sewage Disposal &........................h.... ca n :\ddrrss �. � L! �� or Lot.-No- i� ..... .�....._ ................. ..•--....._._.__....__..__......._.._....._._..._ _.........__..........____....................._................_..............................._. �- cr ------------...Address Installer Address / 7 6 //c d /Y_ of Building Size Lot.___......._._.........._..Sq. feet U Dwelling— No. of Bedrooms __._.. __-__Expansion Attic ( ) Garbage Grinder ( ) '�'�J/ a Other—Type of BuildingAi0q l._--- No. of persons____________________________ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------� _ .............................................................. W Design Flow--------------------lla....�:......gallons per p,srsen per day. Total daily flow.............. ..........................gallons. WSeptic Tank—Liquid capacityl aal ions Length________________ Width---------------- Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------_-_---._.-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit________---._.--__-_ Depth to ground water........................ fr4 Test Pit No. 2................minutes per inch Depth of Test Pit-_._____..._____-_ Depth to ground water........................ 04 0 Description of Soil.......a4Gam. ........ U ---•-----------•-------------------------------------------------------•--...----•------......------------------------------------------------....-•------------•----•--•-------.......•-•-............_ W 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed/ ......... . •............ ....................................... Date Application Approved By ........... ......./ 1- Mce Application Disapproved for the following reasons: ......... . .................................................................... ........ .................................. ... ........................................................................................................... . ..............................................................-- ............. ..... ......... ....................... ....�..�`.—.. �_ Date Permit No. ........ ...... ......................... Issued .................................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THE-IS TO CERTIFY T at the Individual Sewage Disposal System constructed ( V ) or Repaired ( ) by .....,7 1..:. .12....�CG�. . _...... ---- ----- ----- .__............................_........... j' In r II•r t .. ' . ..}. VIL.L�............ .... . ...a ........ / ...... . has been installed in accordance with the provisions of TITI.E S f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ._.��.�...:5-60........... dated ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL,FUN��N SATJSFACTORY. DATE ....................._............_............. .... - Inspect ............... ►..._........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No..r a•' �•- FEE....e�Us ........ Ropmal Workn Tnni#rudinn Vantit , 1� ,2iSC d1- Permission is ereby granted------.T7"---------------- - -----------t�------------ ....................................................................... to Construct or Repair ( ) an Individual Sewage Disposal System at No.•-4' -T-......a........ /�-A....... OG S�-•-•-•w � � 045 �`;✓/LL ............................................................... Street as shown on the application for Disposal Works Construction Permit No./ Dated......... -.�-�.-.'��.... L Board of Hcalth r� DATE---------•----------� ? �::-17-/------------------------------ FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS No.:. .. Fait.... . ........ z� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLEV :. •.��rltrtt# nit fur �lt��l��ul �ii nrk� Cnngt�#rnr#inn �rxuti# Application is hereby made for a Permit to Construct ( 1/�or Repair ( ) an Individual Sewage Disposal System at: Utz' - �.(f • ..................... .... .•• --•-•-------------- ---------- ..... ------••-•--.......--- ....-----•-----------...... Locat-in-Address 1• �( I t or Lot No.------------- .... a� ................ r ws5er Address -------------------------- ------------- ---- . ----------....... �� Installer Address �CSq. feet ype of Building Size Lot............................ U Dwelling No. of Bedrooms.---•-_�--__-_-_____ .Ez Expansion Attic►-+ g— : J'/ � -- ----------------- p• ( ) Garbage Grinder ( ) aOther—Type of Buildiug� �7_l�. No. of persons____________________________ Showers ( ) — Cafeteria ( ) dOther fixtures . ---------------------•-............................................................... W!� Design Flow..................... 1 __.._�__..--gallons per person per day. Total daily flow_.._........ ? .............__....gallons. WSeptic Tank—Liquid capacity<5 gUgalIons Length---------------- Width................ Diameter................ Depth............'i' x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..__--_-.---_-.---- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------------------------••--•--•••---•-•-• .............................. Date........................................ Test Pit No. 1................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........................ a .- ---------------------------------•-•-------------•---•----.................................................................... C) Description of Soil-•_....42 _..z2aJrn--------------------•--•-•-•--....._..-. x p � / .......... U .....-•••••••-••--•••-....••-----•••._...------•-••--•-••••-••••••••••••............•••••......•-•...•••••--•-•-••---•..............••-•-•--•--••...._....---•-•.................._...........-•------••- 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed� o-- ..oC 111�1 ..................................... ....................................... • Dace ApplicationApproved By ....... ..O . . ...�� r c�.......................................................................... Dare • Application Disapproved for the following reasons: ..................... ................................................. . ..................................................... Date PermitNo. .........`....��........5.. .................. Issued ........--......................................................... 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