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HomeMy WebLinkAbout0027 WINDLASS LANE - Health 27 Windlass Lane Centerville A 192 072 ' I SI�__�_Jf �J�3KrClfoco UPC 12534 No.21_ 53LOR �„ �"Q HASTINGS.UN i; -\ COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9 hm p� L+ , Owner's Name: '' Owner's Address. r' C) CA) Date of Inspection: U; C) Name of Inspect lease pr'nt) r Company Name. N Mailing Address: ' /A c��7� �. ` Go mil T o M Telephone Number: CERTIFICATION STATEMENT 1 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 DE.P approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: V Passes Conditionally Passes _ eds Further Evaluation by the Local Approving Authority . F ils Inspector's Signature: Date: 11 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditionsof 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 1 i , Page 2 of I 1 s OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: " _ 1. i Owner Z6 Date of 1&pection: 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 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 11 OFFICIAL INSPECTION FORM - NOT--FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address / 0 , Owner: — Date of I spection: C. Further Evaluation is Required by the Board.of Healthy 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 Z. 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 Page 4 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY,ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 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 I/ 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 T Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number lof times pumped Y 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. _ V 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`certifted 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.] 40(Yes/No).The system fails. I have-determined that one.or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with.a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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—I WPA)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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: M Owner: ice, Date of I spection: . 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 ,Z_ Has the system received normal flows in the previous two week period? ZHave large volumes of water been introduced to the system recently or as part of this inspection? V 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 backup 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 affles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? w v' with information on the proper _ Was the facility owner(and occupants �f different from owner)provided p p 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner-:11 Date of I pection: FLOW CONDITIONS . RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): DESIGN flow based on 310 C�5.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder yes or no): f" h Is laundry on a separate sewage system(y s or no):l:le[if yes separate inspection required] Laundry system inspected(ye,,t or no):, . Seasonal use: (yes or no): Z �� Water meter readings, if all (last 2 years usage(gpd)): _(�3 "y $B� _� j Sump pump(yes or no): Last date of occupancy: e t COMMERCIALIINDUSTRIAL A10 Type of establishment: . Design flow(based on 3.10 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: Was system pumped as part of he inspecti n(ye or o):—,,/,4 If.yes,volume pumped:. gallons--How was quantity.pumped,determined2, Reason for pumping: a TY 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): Ap oximate age of all components, date installed(if known) and source of information: Wer sewage.odors detected when arriving at the site(yes or no): 6 Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of�Ispecjiion-: BUILDING SEWER(locate on site plan) Depth below grade: 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: Material of construction:2concrete_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:�•,�� SC'� _ 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 nr baffle: lZ How were dimensions determined: Comments(on pumping recommenditions, i6fet and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert, evi e ce of leakage,etc.): i r GREASE TRAP(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or.baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(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 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Off Property Address: lien Owner Date ofinspection: ,aya 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/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: V if must be o ened locate on site plan) � present P )( P ) Depth of liquid level above outlet invert: �� % Comments(note if box is level and distribution to"outlet' qual, any evidence of solids carryover,any evidence of ahage intp or out of box, et ): PUMP CHAMBER- locate on site plan). Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note.condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / Owner Date of I spection: , �v SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ aching 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 vegetatio , e c.): t �e O• �� 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 or no): Comments(note condition of soil,-signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY./)6(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 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: ✓d.A 4A, / Date of nspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. , ow Act � S . o PC"� I 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A Owner• Date of spection: SITE EXAM Slope Surface water Check cellar Shallow wells-' Estimated depth to ground water 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: Checked with.local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: o Q 11 Permit Number: Date: Completed by: � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: / W O���i�L ��� Lot No. Owner: Qdn��/�T ; G�/?1"5e5 Address: Contractor: "4, I�J4� 0,5<5PI"" Address: !55 Notes: STEP 1 Measure depth to water table ` /U to nearest 1/10 ft. ............................................................................... .Date month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine:OA Appropriate index well.................................�Q....�.......... Z5 OB Water-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to V7,1 water level for index well ........................... 7 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .......................................................................................... Z STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................................................................. Figure 13.- Reproducible computation form. 15 /a0 O �00C, l.. �..ri,. .,V, �r,���� � ..����r- ors _ • N . - Fee y d THE COMMPNWEALTH OF MASSACHUSETTS� Entered in computer: t . Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zippltca i " fo. a'e*potem Con5tr uction Permit Application for a Permit to Cons !tr(1 Re at)rComplete) Pgrad Abandon ❑Com lete S stem ❑Individual Components nents Location Address or Lot No. 7 5� `,N Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 Installer's N/ e,Address,�TeloG Designer's Name,Address agd Tel.No. s r� >o� � � �( Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow f a gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title q J r Size of Septic Tank l Type of S.A.S. y`--rS Description of Soil Nature of Repairs or Alterations(Answer when applicable) gl(AJO 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 provis' o it e e nvironme Code and not to place the system in operation until Ce ' t- cate of Compliance has b n issued by t ' f th Sign Date Application Approved by Date Application Disapproved for the following reason Permit No. Date Issuedff * -No. / +__ Fee z THE COMMONWEALTH OF'MASSACHtASF_TTS� Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLES MASSACHUSETTS Ztpprication fo A(( -), at *p tem Construction Permit W/N� Application for a Permit to Construct( )Repair pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. N Owner's Name,Address and Tel.No. Assessor's Map/Parcel Z 0 s Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �o�S��� , o�Z-"jc. 3a5� �F-� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. .Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) 1 Other Fixtures [, Design Flow 5 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title f Size of Septic Tank j 60 D aq I d Type of S.A.S. lux Q or'S 1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) N r 4? /F' r' r — �k t% 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 of a nvironmep of Code and not to place the system in operation until Certi i- cate of Compliance has 1 f�ssued b this- oa� of e It O/ Signe r' Date /� 7 Application Approved by +a Date Application Disapproved for the following reason ` W Permit No. i Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CEUIF—Y-, th t the- he d On-site Sewa a isposal System Constructed( )Repaired Upgraded( ) Abandoned( )by N ✓v , o .t/ 1�u C_ at / 0.s s r,--6&e,e 0 f �'' has e constructed in accordance with the provisi and for Disposal System Construction Permit No. ated Installer 4 BNH,-aft) Designer Mr > So N The issuance of this ermit shall not be construed as a guarantee that the system will function as design—ed. Date If � � b D) Inspector G�rr 'w J No. Fee ..� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mlopomt 6potem Construction Permit Permission is hereby granted to Cons . q( )Re air(x )Up rade( )Abandon( f System located at mot/ i'y tS �' � and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction % ust be completed within three years of the date of this permit. Date: �� if l Approved by � , : ��}n��7}'''+ g t 'v ua ti^z C ✓. _ 4"' ''v, `$".. tns:"•�irfTa zv- p #� .�. + a� � lt'r'7S'� Sy`.? f,. 3y •a'y,, ,3 N `Sid^ Rb�° {k'Ai,tC"S".R-t'�..t..4 �; \'••e^.•FaRj'' jp'� y'+C- �3. �e�+-.f> s,+rE�>v LOCATIO Zx SEWAGE # tfil 7 $~ J .�'c-u; �'"3 [�.*,�,•,*., W-tY'-` u' .; �,.. ��t ... t' •' :1 . t. •t n `'_: i,. y 5„ ;, _ VII:LAGE -' f ��a ASSESSOR`S MAP&LO'F lh INSTALLER'S NAME&PHONE NO.. �'� G,�n 1 S rV r SEPTIC TANK CAPACITY Q Crc LEACHING:FACILITY: (h'Pe)' (size) L,3 •..1'E- t NC:`OF-B•EDROOMS i • k.. BUELDER OR OWNER 1) PERMIT DATE: ' t,OhV1PLI�►NCE D.�TE. . i ,.." f ! •, b.'. Ir,, t r � f N ;t., , f .. x •t ...• . ' Separation Lis('anc�'Betivea the Maximum Adjusted.Groundwater Table and Bottom of Leachung Facility Feet Private:Water Supply Welland Leaching Facihty (If any;wells exist } ' k N on site or within 2 0 feet_of leaching facility) Feef 7---�- Edge of Wetland and Leaching Facility(If any Wotlands e7.1 M }1 wtlin:300 feet of leaching facility) F„et f t }+urnished by f i Y rf t x A h ✓ 1 ,+,, b -41 .- - _• t. r a � t t t� }t, s I � t.' t� �fzFl„ti--.Rp i��Y�}!�k t'�. i �s s ' 5 y t t I I 3 t y� . :• ^. 'lit � 5' � t D:34 a � /}= EJO �•GS6 r� _ � 3� G a. TOWN OF BPANISTABLE 5C- \ I LOCATION c�-7Ltn1'/;� II,cSS CAP, SEWAGE # vJ 7 L V^ILLAGE ASSESSOR'S MAP & LOT ��►�.U 7 INSTALLER'S NAME&PHONE NO. 4 h C j)tad',kw c'T 0h SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 1. ;�i h (size) 3-3 syl NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE:' 12,001 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist r 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 ECO A-® -q ' aE13b - - �•� .�GF `�`�`'s`_ - ,v 3� Gar Commonwealth of Massachusetts Title 5 Official Inspection Form rA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ^ 6 9&101 Q /44 Owner Owner's Name information is ��� 4 � ) required for every � �� page. City/To_ State Zip Code Date of Ins 9 coon 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 forms A. Inspector In r ion on the computer, use only the tab key to move your Name of Inspector cursor-do not use the return Company Name key. Q Company Address O'D 7 P1 Ct.J C. rim City/Town� Sate �D Zip Code P Tele hokumber Y License Number B. Certification 1 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 sys 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails inspectors ignature 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. 5insp.doc-rev.7126/2018 ?iUe 5 ot`idai inspection=or .suosurface Sewage D!sposal System-Page 1 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form r IN Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lass ot/ Property Address 44 C O N✓�O`I Owner Owners Name information is Ce N 4rv/114f D�ro �/ /I /^required for every �/ page. City/Town State Zip Code Date of i specti n C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) ;te sses: 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): t5insp.00c•rev.7/25/2018 'roe 5 075aai mspecaon Fom Suosurace Sewage Disposes System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / ✓!✓10�l /infoOwner Owner's Name kev,( rmation is 4 required for every - �w page. CitylTown State Zip Code Date of Inspecti n C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: [5insp.doc•rev.7/25/2018 -itie 5 Official Inspeccon Form:suosu:'ace sewage Disposal system•?age 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Co 0 0 d9 / Owner Owner's Name information is all required for every page. Cityrrown Stale Zip Code Date of ins ection 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 wetiand 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 up 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 Title 5dsi'nspec�or,=o:-:Suosurfdce Sewage Disposal System•?age 4 of 18 Otfit5insp.doc•rev.77Z82018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6-1.,10A s5 z— 41 Property Address, Owner Owner's Name ,l l information is Q� Vd ;Date �0 required for every page. City[Town State Zip Code of Ins ction C. Inspection Summary (cons.) 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 han'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or LLLLLL{{{{{{dddddd'''"' obstructed pipe(s). Number of times pumped: [� Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portionof cesspool or privy is within 100 feet of a surface water supply or ❑ ;/00' tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. i l 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.] e system is a cesspool serving a facility with a design flow of 2000 gpd - 10,000 gpd. r, The system fails. i have determined that one or more of the above failure J 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 0.4. 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 It of a public water supply well ';tle 5;Vfcai;nspeuion=or:suosuce SewageOisoosal System•Page 5 of 18 ,5insp.doc•rev.M 2018 <N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for/Voluntary Assessments / Property Address N V)p //07 Owner Owner's Name 9 information is �` H ! /�. required for every Ce page. CitylTown State Zip Code Date of Insp on 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 N ❑ P ing information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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) r ❑ 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)[3.10 CMR 15.302(5)] I tSinsp.doc-rev.7/25/2018 7iiie 5 otaat inspe.�Jon=on:su5surtace sewage Disposal System•?age 5 of 18 t\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address oj4 44 Owner Owner's Name inforrnation is f required for every Q CitylTown State Zip Code Date of Inspe on page. / D. System Information ��A ��� `f OV7 'M1 �z .1. 'Residential Flow Conditions: /J � � m Number of bedrooms (design): Number of bedrooms (actual): 3 3c DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: /DO� // 4f G —r5 1__/&_�o ele, S.3 -/ /0 0_ L Number of current residents: ❑Does residence have a garbage grinder? Yes o _, N Does residence have a water treatment unit? ❑ Yes i Qo If yes; discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Yes L__ /' ❑ Laundry system inspected? ❑ Yes 2_'No Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: 6Zse1*`No Sump pump? ,cw Last date of occupancy: Date Tice 5�idai I.nspecnon=cmr.Sucsu'zce Sewage Disposal system•?age 7 of 18 t5insp.doc•rev.7128/2018 Commonwealth of Massachusetts ,. Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address lit� ►v Owner Owner's Name information is ��� ,A,_✓` � required for every 1�.� "i'�/ page. City/Town State Zip Code Date of Inspe, tion 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: Was system pumped as part of the inspection? I I Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.00c•rev.712812018 7iae 5 otfidal Inspection=0 mn suosur ace Sewage Disposai system•?age 8 of is Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owner's Name t information is � ��� required for every page. City(rown State Zip Code Date of Inspe lion D. System Information (cont.) 4. Type of Sy 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 ag�ail components, date installed (if known) and source of information: 71Ef n arriving at the site? ❑ Yes No Were sewage odors detected when g 5. Building Sewer(locate on site plan): Depth below grade: feet Material of constructio;4eO ❑ cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 'itie 5 otdai inspection Foy.suosur,,ace sewage Disposal system Page 9 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C� ul t4 J/., Property Address Mv- ✓�0 Owner Owner's Namif information iseft -vtrequired for every y ✓ page. City/Town tate Zip Code Date of Inspecti D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grad feet Materi 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 certificateL ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle SCcr v� 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, ctural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): A4 0"—,/ t 0 Qs o C00j,410VI, ?age 70 of t8 t5insp.doc•rev.7t2612018 I itie 5,7fcai;nspe=cn=0' .suesurtace sewage Disposai System• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address // Owner Owners Name v` information is / A; required for every State Zip Code Date of Inspe ion page City/Town D. System Information (cost.) 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.): at time of inspection) (locate on site plan): 8. Tight or Holding Tank (tank must be pumped Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day -i0e 5 Cff�aa'inspecuon Pow:suosc ace Sewage Disposal System•?age n of 18 t5insp.doc•rev.7/2612018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d A z,,r/- Property Address / � NV1d/ owner Owners Namreo: kinet information is required for every page. Cityffown State Zip Code Date of I spectio D. System Information (cons.) 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): Z— val Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): /V-D .,�e- ?;Ue 5 pificai tnspecuon Suos:.face Sewage Disposal System•?age 12 of 18 t5insp.doc•rev.7/2612018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address l 00 tit O! Owner Owner's Name /�� information is 1.44��t t� required for every State Zip Code Date of Ins ction page CitylTown D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * if pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: 71 leaching galleries number: ❑ leaching trenches number, length: leaching fields number; dimensions: overflow cesspool number: ❑ innovativeiaitemative system — Type/name of technology: -iue 5 as',nspex or.Fcm:Suos'nace Sewage Disposal System•?age 13 of 18 t6insp•0oc-rev.712612018 Commonwealth of Massachusetts Title 5 Official Inspection Form �t Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address //62 N ✓1 O Owner Owner's Name r / /� information is v� required for every page. CitylTown State Zip Code Date of Inspe on 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.): vile- tA alt.. o S, .� O law lL 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.): •Pae14 of 18 _ � - 'ewa a Dis sai System9 Tile a(�f5ca inspeC�on,orrn x: csudece� 9 po t5insp.doo•rev.7fZ6/2018 Commonwealth of Massachusetts Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C (A/(j4 Property Address // Owner Owner's Name I information is required for every --rr'rvivv _ al page. City/Town State Zip Code Date of Inspe tion 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.doe•rev.7/2822018 'me 5 C,h al,nspeCDOn=orm.S'osu-ace Sewage Disposal System•?age t5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4? Property Address / �pNt4O Owner Owner's Name information is required for every e h (�! 0A 6 octio page. City/Town State Zip Code Date D. System Information (cont.) 14. Sketch Of Sewa Disposal System: Provide a vie f the sewage disposal system, including ties to at least two permanent reference land;bu rk r benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the ng. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately i i i l i � n � � f Sep�c� Ta K l✓ i T C I� e C�94oz � Lam."It i C wl s4o [-� i i t5insp.doc•rev.7/26/2018 Title 5 c`dai lmsG--ion=om:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary oluntary Assessments Property Address 44 C�J — Owner Owner's Name Co0Km !/ information is required for every WKi ` page. City/Town State Zip Code Date of ln?f edon D. System information (cont.) 15. Site Exam: Ll Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /f/Vv4— Estimated depth to high ground water: 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 ❑ bserved site (abutting propertylobservation hole within 150 feet of SAS) Checked with to Board of Health - explain: l 80%s' I Checked with local excavators: installers - (attach documentation) ❑ Accessed USGS database -explain.- You must de -be how you stablished the high ground water elevation: 1 -0 Z r SAQI�n t✓ v^7 C) ti-f// —r-76 .&Zco d(Ae- v--► 10, / Per IG • • Slido Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6insp.ioc•rev.7262018 -iue 5 SSaa;:rspe=on Fa^:Suasur ace sewage Disposal System•?age 17 of 18 a � Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address AG 0(A 94 0 Owner Owner's Name information is Q� required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all ap licable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. . Certification: Signed & Dated and 1, 2, 3, or checked C. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failu Criteria)and 6 (Checklist)completed 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.Coc•rev.7/26/2018 .:tie 5 oftaa mspeaion Fa-:.suosurface sewage Dmposai system•?age 16 of 18 /* L&CATION SEWAGE PERMIT NO. VILLAGE Of INSTA LLER'S N ME & ADDRESS Sun i AA A&O 11�t/►�2� SC)GZ� B U It D E R OR OWN R R DATE OERMIT ISSUED DATE COMPLIANCE ISSUED i a QQ Fms.... .. . THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEA�H ...OF ..... .... . .:... . ...:...:..... ....._C.. ... ............... Appliration -fur Biavnsal Workii Cnotu4rurfion Prrmil Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at Y � ........... --------------------------------------------------------------- , ca (� i ... ----- --•--••------•-----•- ------------•-------------- -- - a Owner. a Address` a ........... �/1/ !L•------ --•-------•--•-•• ----------------------- --•------ -- Installer Address Type of Building Size Lot.........;_7/__ O 6_Sq. feet Dwelling—No. of Bedrooms-."-_____ ..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) A' Other fixtures --------. _._ ___ W Design Flow..................°mod----------------gallons per person per day. Total daily flow---............ ..-0_............gallons. 04 Septic Tank—Liquid capaceo pggallons Length................ Width...... Diameter__"--...__.___ Depth.--."--"-_-..... Disposal Trench—No-------------------- idth.___._____------_ _ otal Length---------- _.....-- Total leaching area.___- --- ..asq. ft. Seepage Pit No._._j.0�0�� ----.._.._ Total leaching area------------------sq. ft. z Other Distribution box ( Dosing tank /, -J"-'-7 aPercolation Test Results Performed by.......................................................................... Date---------------------- ---------------.. W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----------.--."--.-----. f� Test Pit No. 2----------------minutes per inch Depth of Test Pit."--.--__-________ Depth to ground water------------------ --- Fy _______'__f;_-"______/_/___________ _ _ _ _________•---.---_-_____kDescription of"Sotl _-------- _.. ...,X- - - x �, 7� T - ----------------------------------- ----------------------------------=------- 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 Article LI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by th/ oard pf healt S' e '�`''� -- -- ---------------------------- l ate Application Approved By...— fld�J/LG ....... ' 7 " Date Application Disapproved for the following reasons------------------------------------------------------------------------------------- ---- ------------------- ----•------••••-•--•-•---••--••-----•-••--•-----•----•--------•-•--•••--•-----•-•--------•-•--••----•--•-----------•--------------••------------••-••----•-------------- -. --------------------------- Date PermitNo......................................................... Issued........................................................ Date 21 THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH, ,/ ..................... OF.. .................................................................... 101rdif iratr of Tompfiatta THIS-IS TO CERTIFY, That the"Individual Sewage Disposal System constructed ,(--) or Repaired ( ) by le- ............................................... / s Installer ,� F at.......--------------------------------------------- - ------has been installed in accordance with the provisions of Article1XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated----- _-._----___-__-------.._.-_--_-------__.... THE ISSUANCE OF THIS CERTIRCATE SHALL NOT RE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- `-a. L Inspector....=' s`` ".. THE COMMONWEALTH OF MASSACHUSETTS BOARD /O�1F HEALTH__ .............. ............. .... No..-•-•------•----•-••--• — FEE........................ R-riVv ial f rk ��tt �r r#i tt rant Permission is hereby granted____________ A✓ A/ e ('' -•----•-------•- ...- to r Construct ( '�)o Repair ( ) an Individual Sewage Disposal System .10, / at No.. �I, ----------- " t' '1 r' ' ' /`! �! --- -- - - --•---•---- u. treet as shown on the application for Disposal Works Construction Permit No--------------------- Dated.......................................... -------------•-------•--•---•----------•------•-•--- .................................................... DATE---- Board of Health -------�- ----^--�-� FORM 1255 HOBBS & WARREN. INC., PUBLISHERS No......................... Fxa.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rI ........ - .OF.............. ...................................................................... Appliratinn -for Diipviittl Morkii Cnotuarurtion Vaulit Application is hereb made for a Permit to Construct pp y' ('�.—)-or Repair ( } an Individual Sewage Disposal System a� Location-Address or Lot No. !-..•... ' Owner /� Address ' f/` � Installer Address U Type of Building Size Lot..... U-Sq. feet Dwelling—No. of Bedrooms--------------_._____________________--__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ________________________--- No. of persons...........----------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------=-==.... _f! -----------------------------------•-•------------------•--------------•-------------------•--------------•-------------- W Design Flow per person per day. Total daily flow---------------------- __.....__--gallons. Septic "I::nk—Liquid capacity gallons Length---------------- Width-------__... Diameter---------------- Depth....___-_.-_--- xDisposal Trench—No. .................... N idth___-_-__-.__-.._�:_ Total Length..........2�........-Total leaching -,-;7-_.,.sq. ft. Seepage Pit No.....t�.j!.-e- U Dlamete>t-- ----------- �Deh �below'inletT! .. Total leaching area----.__ ----------sq. it. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- •---•----------------•---- Date------------- •----------------------- a a Test Pit No. I----------------minutes per inch Depth of Test Pit___.__..___-______ Depth to ground water...____._____.___.----- fl-4 Test Pit No. 2----------------minutes per inch Depth of Test Pit._.___---.________- Depth to ground water_-._____._______-___._. ...-•------------------ -------•---------------•-------------------•---•-------.----------•--------------------------- ------ -----------------------••-- -- 0 Description of Soil------------ -------------------------------------------•---------------------------------------------------------------------_-_..----------._------------ ------------ x U ------ VW ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by fthe,board`of health., Signed � . ---•/--ry Date---•- :�•f--------------•-•------••-•-------- --..1__•_._- --- Application ----- Approved By---•-------•--•-•------------------•-------•---•-•--------.--•------------•------------•-•------ Date Application Disapproved for the following reasons----------------------------------------------------------------------- ......................................... -------------------------------------------------------------------------------------_- ------------------ Date PermitNo..................................--•---•---•----•••--•- Issued-----_--------------- ---------------................. Date LOT (-o N ,/0' Ito Gbly �- � � TA$.lv- r r lot F-K,JED, �z �`9* - rt` / 0 . 1 � Q L C) off ;. RICHAfiC3 �� E3AJc'rEA � .:� CEIZTiFialD pi✓o'r • �Q ST! _ � o 5UVO LOCATiC IJ CENTE.R IL.L-E., t` "",Ss i C G R T 11= A i T 14 i= W-DA-T VOW S ►J Wi--QtcGtJ C�cA�>. W1 TtA Tt-ice 51DEltt-1� KNO► Ty `tliLL.NCa �, 41uC:> SETt3/��K CSC-L�UiiZ�Nict-±jS G1= Tt+ T G bV 1 1 G1r �rZ S r�41_C L'�. Z 3 P i 2,7 LOT 5 G t2GGlS iZiZi=C� i�l�ip StiZ�'`.`r'o►=S Ti-1i5 V"At-1 IS "OT 0,-t 4w U5'it2Vii_LG u /vCASS. IWST'�v�vti=tJ i `iUzvi—f 5,�- Ti4C C:r=t=`iici S x fi4i .Jt._C> APc�t_t Gn.tiT t`U-r 611 l%`iCtJ iv Di=TL MIMIC LC:'T �I►�i�5 G�F� �( IZ:1 i/ t�0 3 ASSESSORS MAP : /9 _:_-- TEST HOLE LOGS -_- , � PARCEL: �_7_Z.- - __--___ , _ ___-_-- ----_ ------ ---_._ SOIL EVALUATOR: I `II a�l,.-I l,' 'PUf FLOOD ZONE: A./ h�GtGG _ _ --__ _. -- y _ _ ._ WITNESS : V� � y REFERENCE: _. DATE: I _ �_ 8,_ .- 'R�l.�c�1.._p>�' �J��-��J d! PERCOLATION RATE: 2 IL- Z,_..' r (1�� � ��i"C L'L'.._ .VI!i�U�.. - a�' to �'� . .__ _ 1 �Ly_�_. 'w�C.� PbwrC�� - OLTj TH- 1 TH-2 --- --- _ .. LOCATION MAP S� �'; 1b ��� rv�2._. 2aP�.f2. �t�-11� 71 NT; - IF 7e-CPL4d;16,t 6 - ��,31 �'PPLI(,Vj�r Gz W h�l�y �' SYSTEM DESIGN GN = - ._.. T;17. SEPTIC _.c , i ►q- �. , FLOW ESTIMATE _�_ _ Q, o�/ SZ_._._ ."n' •� 3 BEDROOMS AT GAL/DAY/BEDROOM GAL/DAY SEPTIC TANK 3%) GAL/DAY x 2 DAYS �loGAL ` S TA USE �`�� GALLON SEPT I C TAN 11 (3 ON11O A-1CF1 IL LP � SOIL ABSORPTION SYSTEM -�- / 5� -- ©ion 7Z - %eAl1?, POT r - SIDE AREA: 1��C. � { 6�'Y `t i BOTTOM AREA: ' -o( 01-7 L z jo y Q ,., TIC G SYSTEM SECTION -� .. , ON n l� _ � � .► � � i ck GAL La S PT bvt"f�' I �+5t.�. W 1-�uU 4V�F, PNtoOFM,�s UONALD sycZ DeLANO C- NNoo.29868 r SITE AND SEWAGE PLAN su {. LOCAT ION : WIW 1, ��1 - _ I� VIV1. PREPARED FOR : hAgoUAt) I; m"4E 0L)W SCALE VVV DAV I D' B . MASON DATE: 21 D cg DBC ENVIRONMEN AL DESIGNS DATE SANDWICH . MA ATE HEALTH AGENT ( 508 ) 833- 2177