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HomeMy WebLinkAbout0071 WINDLASS LANE - Health 71 Windlass Lane Centerville P A = 192 075 =JAcY«o�o� UPC 12534 0 �� No.2153LOR HASTINGS. UN it i ' COMMONWEALTH OF MASSACHUSETTS 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 _ ENOV VED Property Address: 71 Windless Lane Centerville, MA 02632 Owner's Name: Paul Gaudreau ZOOS Owner's Address: STABLE PT. Date of Inspection: November 3, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Map: 192 Telephone Number: (508) 862-9400 Lot: 075 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 Nee Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: November 5, 2003 The system inspector shall subm' 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 71 Windless Lane Centerville, MA Owner: Paul Gaudreau Date of Inspection: November 3, 2003 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: 71 Windless Lane Centerville, AM Owner: Paul Gaudreau Date of Inspection: November 3, 2003 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic 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 h t facility g p pthat 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: 71 Windless Lane Centerville, kM Owner: Paul Gaudreau Date of Inspection: November 3, 2003 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 'h 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. 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 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 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: 71 Windless Lane Centerville, MA Owner: Paul Gaudreau Date of Inspection: November 3, 2003 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 Windless Lane Centerville, MA Owner: Paul Gaudreau Date of Inspection: November 3, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): 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)): Unavailable. 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 (Y :stem discharged to the Title 5 s es or no g Y ) Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 1999-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: Flow diffusors were added in 1999-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71 Windless Lane Centerville, MA Owner: Paul Gaudreau Date of Inspection: November 3, 2003 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: 20" 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: 1000 gal. Sludge depth: 1" 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: 13" 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.): The tees were present. The liquid level was even with the outlet invert There did not appear to be any 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 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71 Windless Lane Centerville, MA Owner: Paul Gaudreau Date of Inspection: November 3, 2003 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: eallons 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 leakage or solids Speed levelers were present The cover was approximately 3' below grade. 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 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71 Windless Lane Centerville, MA Owner: Paul Gaudreau Date of Inspection: November 3, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'(1000,ga1.) ✓ leaching chambers,number: 2-flow diffusors with 4'stone 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 original leach pit was in failure in the vast-per owner and last inspection. The cover was 3'6"below grade The bottom to grade was approximately 96". Flow diffusors were added in 1999. The flow diffusors were dry. A video camera was used to conduct the inspection. The bottom to grade was approximately 7' There did not appear to be any signs of failure 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: 71 Windless Lane Centerville, MA Owner: Paul Gaudreau Date of Inspection: November 3, 2003 Map: 192 Lot: 075 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. a 3 Q 30 O � 3 yi a� y ti� as 10 Page 1 1 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71 Windless Lane Centerville, AM Owner: Paul Gaudreau Date of Inspection: November 3, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +1- 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 9'6" Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 30'+1-to groundwater 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 [ A J TOWN OF BARNSTABLE LOCATION �1 �114C �, / Z �^/-VA'L SEWAGE # VILLAGE Ct.Te eat 14- ASSESSOR'S MAP & LOT l�la" 075' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J f LL n LEACHING FACILITY: (type) ��/UD ��T' oZ t-�4G�rs (size) NO.OF BEDROOMS—�� BUILDER OR OWNER � !!-!LIT . U tJ/EAU PERMITDATE: 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 leachin%g facility) Feet Furnished by IV-17PC07on -S- �0/� 3 Q y ft-173 ( o O 3 Y/ al y y-7 as. TOWN OF BARNSTABLE LOCATION I (/)JA10/1 A.9-5 L ,l AI e SEWAGE # J9,9- qI VILLAGE_ C e,41fe p V/Ile ASSESSOR'S MAP & LOT - INSTALLER'S NAME&PHONE NO.' J V.,/• A4 A C o M e d✓7- 56h SEPTIC TANK CAPACrry l®0 6 — /"/Z/ LEACHING FACILrry: (type).'fLBW,111,4AeeR`S (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of,leaching facility) Feet Furnished by a% � e / Q i I COMMONWEALTH OF MASSACHUSETTS 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: 71 Windless Lane Centerville, MA 02632 Owner's Name: James Decava Owner's Address: Same Date of Inspection: July 16, 2001 ` ZL2 Name of Inspector:(Please Print).James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterpille,MA 02655-0049 Telephone Number: (508)862-9400 Lot. 075 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 Nep4 Further Evaluation by the Local Approving Authority Fa is Inspector's Signature: Date: July 18, 2001 The system inspector shall sub" 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 1 r Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 71 Windless Lane ;a Centerville. MA _ Owner: James Decava Date of Inspection: July 16, 2001 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".Oleme 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 ass 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: 71 Windless Lane Centerville. MA - Owner: James Decava - - Date of Inspection: July 16, 2001 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 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ;CERTIFICATION (continued) Property Address: 71 Windless Lane , Centerville, AM Owner: James Decava Date of Inspection: July 16, 2001 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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone l.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. 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 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 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: 71 Windless Lane Centerville. MA Owner: James Decava Date of Inspection: July 16, 2001 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 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 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C "."SYSTEM INFORMATION PropertyAddress: 71 Windless Lane Centerville. MA Owner: James Decava Date of Inspection: July 16, 2001 FLOW CONDITIONS RESIDENTIAL ' Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [ifyes 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)): 2000-38,000 gals., 1999-25,000 gals. 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 Basisof des'ign,flow(seatslparsons/sgft etc.): r ` 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: Pumped in 1999-per owner Was system pumped as part of the inspection(yes or no):_ No If yes,volume pumped: Qallons--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) t' ' Tan Attach a copy of the DEP approval _ Othef(d scribe) Approximate age of all components,date installed(if known)and source of information: Flow diflrusors were added in 1999-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 i Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION (continued) Property Address: 71 Windless Lane Centerville. AM Owner: James Decava Date of Inspection: July 16, 2001 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: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene Y _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: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" 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: 13" 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.): The tees were present. The liquid level was even with the outlet invert. There were no signs ofleakam Scum and sludge were minimal. 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 baffler 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 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION'(continued) Property Address: 71 Windless Lane 1 Centerville, MA Owner: James Decava Date of Inspection: July 16, 2001 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 leakage or solids. Speed levelers were present. The cover was approximately 3' below grade There were no signs of backup 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 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71 Windless Lane Centerville, AM Owner: James Decava Date of Inspection: July 16, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'(1000 gal.) ✓ leaching chambers,number: 2-flow diffusors with 4'stone 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 original leach pit was dry. The pit was in failure in the past-per owner.The cover was 3'6"below grade. The bottom to orade was approximately 9'6" The flow diffusors were added in 1999 but were not dug up. The bottom to grade was approximately 7' There were no signs of backup in the D-box. , 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: 71 Windless Lane Centerville. MA -- 1 - Owner: James Decava Date of Inspection: July 16, 2001 Map: 192 Lot: 075 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. 1 3 Ra- 30 O S A3- y 1 A44 - y ray- aS (3S- (00 10 Page 11 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71 Windless Lane Centerville. MA Owner: James Decava Date of Inspection: July 16, 2001 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: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: i You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was`approximately 96". Using the Barnsiable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 30'+/-to groundwater 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 TOWN OF/ BARNSTABLE Co,:ATION wl,,C� f ArllL SEWAGE # VILLAGE GtnT"erv; I LL ASSESSOR'S MAP & LOT I�01 Cf7 INSTALLER'S NAME&PHONE NO. ✓VI, a. ,, ,t♦ SEPTIC TANK CAPACITY I OVD GA I LEACHING FACILITY: (type)P, I + qOW bigXOd(size) dUU SrOna NO.OF BEDROOMS 3 BUILDER OR OWNER J A✓ � ��C-+QViq PERMITDATE: COMPLIANCE DATE: 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 on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility,(If any wetlands exist within 300 feet of leachingfacility Feet Furnished by_ .SPdT�L TnSPcnn • �t7r� A�- ►� 3i - 3(0 �a- 30 A3- y 1 3 Ay- W) AS 8y �s- (00 o No. r _ Fee $ 5 0. 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplicattott for Mi5po$af *p9lem COttgtrurtiott Permit Application for a Permit to Construct( )Repair�X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.7 1 Windlass Lane Owner's Name,Address and Tel.No. 5 0 8—7 7 1—5 4 0 4 Centerville ,Mass . 02632 J.A. Decava Assessor'sMap/Parcel / • A O �1 71 Windlass Lane Centerville 02632 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J. P.Macomber & Son Inc . J.P.Macomber & Son Inc . Box 66 Centerville ,Mass. 02632 Box 66 Centerville ,Mass . 02632 Type of Building: Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons. Plan--Date Number of sheets Revision Date Title Size of Septic TankExisting 1000 TypeofS.A.S. 2-500 gllon chambers Description of Soil Loamy sand to medium fine sand , Nature of Repairs or Alterations(Answer when applicable) Adding two 500 gallon chambers pack ed in 4 ' of stone . 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 Certifi- cate of Compliance has been issue y this la4fopIth. Signed Date3/10/9 9 Application Approved byP IV �" Date Z Z Application Disapproved for the following reasons Permit No. Date Issued No. �� •! - `' Fee $ 50. 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppricatiou for 0i0po.gar *pgtem ConmructiOn Permit Application for a Permit to Construct( )Repair 4 X)Ugrade( )Abandon( ) El Complete System El Individual Components f Y Location Address or Lot No.71 Windlass L a ri a Owner's Name,Address and Tel.No. 5 0 8—7 71—5 4 0 4 Centerville ,Mass. 02632 ^'} J.A. Decava Assessor'sMap/Parcel `' 71 Windlass Lane Centerville 02632 o 1117 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son{Inc. J.P..Macomber & Son Inc . Box 66 Centerville , ' ss. 02632 Box 66 Centerville,Moss. 02632 Type of Building— Dwelling XXNo.of B drooms 3 Lot Size sq.ft. Garbage Grinder( ) ` Other Type n No.of Persons Showers yp g ( Cafeteria( ) ? . Other Fixtures Design Flow '5 5 t, gallons per day. Calculated daily flow 3 x 1 10-3 3 0 gallons. Plan Date Number of sheets Revision Date tf. Title ."` Size of Septic Tank Existin g 1000 Type of S.A.S. 2-500 gllon chambers ;.' Description of Soil Loamy sand to medium fine sand , r{ Nature of Repairs or Alterations(Answer when applicable) Adding two 500 gallon chambers pack ed in 4 ' of 'stone . 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 nd not to place the system in operation until'a Certifi- cate of Compliance has been issue y this oard of lth. Signe Date3/10/9 9 Application Approved b PP PP Y Date -3/1 Application Disapproved for the follo71 reasons t Permit No. Date Issued --------------- ------------------------ f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that ttie Qfi=site Sewage Disposal System Constructed(! )RepaireAXX)Upgraded( ) Abandoned( )by J.P.Macomber & Son Inc. at 71 Windlass lane C e n t e r v i l l a Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - 4� dated ?. Z L19 Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & SON Inc.,' #) The issuance of this .ermit shall not be construed as a guarantee that the s stein will function as designed. Date �� Inspector u',111 �621C/ I I --------------------------------------- No. AI�K Fee$ 50. 00 THE COWONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS 0i5pogal bpgtem Cougtructiou Permit Permission is hereby granted to Construct( )Repair�X�Upgrade( )Abandon( ) Systemlocatedat 71 Windlass Lane Centerville,Mass. 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. t Provided:Construction must be completed within three years of the date of this geit. Date: -3/l � Z//Approved by -�'' TOWN OF BARNSTABLE LOCATION L A &Z SEWAGE # VILLAGE ASSESSOR'S MAP & LOT i INSTALLER'S NAME&PHONE NO. dl ,/t JW A C -0 M if 117. 5'e.41 SEPTIC TANK CAPACrTy /n n d - ,i LEACHING FACILrry: (size) ^C%G t✓AL < NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: '� COMPLIANCE DATE: ,. q Separation Distance Betwe en the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet i Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Furnished by Feet i t / � 0 }' ' 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, J o s e p h P.Macomber Jr . hereby certify that the application for disposal works construction permit signed by me dated 3/10/9 9 concerning the property located at 71 Windlass Lane Centerville ,Mass . meets all of the following criteria: I /The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. V/The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ere are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system Y There is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor Iif ethod when applicable] the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation 3-r +the MAX. High G.W. Adjustment DIFFERENCE BETWEEN A and B �. SIGNED DATE: [Sketch posed p of system on back]. q:health folder.cert 1000 gallon septic tank. 1-Distribution Box 1=1000 gallon precast leaching II pit . 2-500 gallon chambers with 4 ' of stone all around . No.......... t Finc....�.s.................. —� THE COMMONWEALTH OF MASSACHUSETTS y. BOARD F HEALTH /Ow L I� �� .. . . ....OF........ .. ....... ......... ....V Appliratiun -fur Rapuiiat Works Towitrurtiun Vrru it Application is hereby`made for a Permit to Construct r Repair ( ) an Individual Sewage Disposal System at: i iV-4 `" - --•-•--------•------------ 5- ...................................... e V Location- ress q or Lot No. l ..i. �'.._.... e. -�•-•••-----•---•--•--- -•---..... /. Own r _ Address-7f Installer / Address 70 C/C/ U Type of Building, Size Lot........... ___---------- -Sq. feet Dwelling—No. of Bedrooms----------I------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -_._-._-_-.-_------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Al d Other fixtures ------�� --�------------------------------------------------------------------- ----------------------------------------- ----------------- W Design Flow...........4?`!..................... gallons per person per day. Total daily flow........ __0_._..._._..........gallons. WSeptic Tank—Liquid capacit_QaOgallons Length________________ Width.____.._._-__-- Diameter___.__...-_----- Depth................ x Disposal Trench—No- _____________ _____�Wiid _.___.__.. T tal Length___..__ -_ __ of eaching area_.. _ __sq. ft. Seepage Pit No.._.._. ia� -islet fling area..................sq. ft. ./ z Other Distribution box ( ) Dosing tank e G 4k / S'- 7 7, aPercolation Test Results Performed by......___----------------------------------------- -------------- Date-------------------------------- ----- Test Pit No. 1....._----------minutes per inch Depth of Tes� Pit..............1----- Depth to ground water...___.__.__.-. - ------ fr Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water---------------- _---__. W' .................rr S �.... r I o _z1, ---------- Description of Soil C'.� --`-- �z�'e` -`--- -- - -- ...------' - __.2 . ` 7 �� 7 P --- ---�.. x . __ '------- - .- 1 `7, W - " V Nature of Repairs or Alterations—Answer when applicable.-.__..........................:......................................................f ---------------------------------.-'----------------------------------------------------------------------= Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the,board of heal P / a Signe ----�°--••-•----•- �� Date Application Approved By-----?ol ---- . -•.---• •-- � . .....--------- ------ Date Application Disapproved for lowing reasons-------------_------------ -- -------------------------------------------------------------------------------- c4 t ' � I ..................................... ..__--______________- --_�____.___._.........._............_............._.._....._.._____._._...___....___........._______..__.._..______.__.....__..__.__......... 1 Date P mit No.---------•------•--•------- + Issued---------------------------------------••-•--•-•----•-•. y+q Date LOtCATION SEWAGE PERMIT NO. VILLAGGE INSTALLER'S NAME & ADDRESS B U K D ER OR OWNER --R �/ 0 DATE tERMIT ISSUED 7�T7 DATE COMPLIANCE ISSUED Pad � , - � No.- Finc.... .................... THE COMMONWEALTH OF MASSACHUSETTS 4. BOARD-OF HEALTH� co of.._..................................................................................... A Apphration -for EN1imia1 Morkii Ton-titrurtion Vrrulft Application is hereby'made for a Permit to Construct e(�-)_o_r Repair an Individual Sewage Disposal System at: ................................................................................................. .............................................................. ............................... Location-TXdd;V .. .............................. ................................................................... .................................................................................................. owl L., /l_,,,(� 7 ddre7V .................................................................................................. -------------------------------------------------------------------------------------------------- Installer Address 70 C/61 Type of Building Size Lot...... ...` ----Sq. feet U Dwelling—No. of Bedrooms_________ ------------------------- -----Expansion Attic Garbage Grinder ( ) Other—Type of Building --------------- No. of persons_-----_----------------- Showers Cafeteria ( )a4 P4Other-fixtures -----------------------------------------------------__....................................................... ............. --------------------- �, C/ ;/- Cf %-, Design Flow..........................................=t-gallons per pet-son per day. Total daily flow................................._.......-gallons. P4 Septic Tmk—Liquid cai)aci'( ------gallons Len-th---------------- NVIdth----- ---------- Diameter------ ......... De ............(,pth. ---------- Disposal Trench—No. .........---------- Width._._....... .. Total-Lnength------ 2 area.....------ Total . .... sq. f t. Seepage Pit No--_.------©_---- - Diameter-------------------- D(!p-M Below hilet-------------------- Total leachingarea------------- ....sq. f t. Other Distribution box Dosing tank 7-7, Percolation Test Results Performed by.............................------- .............. --------------- Date----_---- -------------------------- Test Pit No. I----------------minutes per inch Depth of Test Pit-.--.-_-_----:-_-_-. Depth to ground water........................ Test Pit No. 2----------------minutes per inch Depth of Test Pit._-.___-__-_-._--- Depth to ground water_...-.-_-___- _-._ --- �+ ------------­­11--- . -- a f._.... ---------------_---- -------_------------ _,z- --------C---- W f Soil___-�=.........0.��------------- .........z......... ........... . .. .... ............ ---------- -------------- ------ ---------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- -------­-------- -------------------------- U Nature of Repairs or Alterations—Answer when applicable------ ----------------------------------- ..................................................... ----------------- -------------------------------------------------------------------------------------------------------------------------------------- ............ ----------- --------------- Agreement: tr The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 the board of health. 7 L S i g/ne ----------------------- ------------------------------------------ ------------------------------ Date Application Approved By.... . . ...... .... ---------------- Date Application Disapproved for the following reasons:......-_-- ............... ----------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ...................... Date 1 6:, Permit No_ q .. -----X":: Issued---;....... 7:­- ee �. THE COMMONWEALTH OF MASSACHUSETTS r �---� BOARD OF HEALTH• Trrtif iratr o$ ITOUIVtiaur THAS,IS TO CERTIFYY1,Thhat the Individual Sewage Disposal System constructed ( ) or. Repaired Y ( ) R b /t t ''r"�— ..� Inst111er at--............... ------------------ ---------------- - has been installed in accordance with the provisions of ,\r'�c e11I'of The State Sanitary Code as described in the 45 application for Disposal Works Construction Permit.No. .. 7.._� ------------- dated...: -----_.- THE ISSUANCE OF THIS CER'TIRCATE SHALL NOTpBE CO'N'STRUED S. GUARANTEE THAT THE :' SYSTEM WIIL�-,`FU fNCTION/SATPF CTORY. DATE Inspector ----- -- --- -------- -------- ----------- --------------- THE'COMMONWEALTH OF MASSACHUSETTS• BOARD OF�'"HEALTH a _ .OF... '.... . ... ............ .................... M o........... ............. / FEE... ......----- �i����ttl .. Permission is hereby granted ---------7 ".-s-," '--� ------'----------------------.-.-.-- 4 to Construct (/)for.Repair ( ) an Individu�a,l�Sewage Disposal System .' at No------------ -. -.If ?< 11.. -'".+�'--'s.' " -------------------- -- --------------------• ----.---- -- .- ----------'--- ------ ---------- ----- -----•--- �.� t/// —zy�.+'v:c-.•. Street 1 :! as shown on the application for Disposal Works C " t Dated _ --- --- ion .............. .3 ( j'r - ?? Board of Health DATE.....51----._ '7-7_7------------------------------------------------- 0 6�• FORM T255 HOBBS & WARREN. INC.. PUBLISHERS - 9 ` o . 8 v i ti r .` I�CC ��ICC (19 All OF-e loot/ G►at(- � + ►.� , c: BAAF cR. PIT 0 .<> LOT 7 P Lo'T• L_ /S,ti LyGAYIUi�+ C E-mTERV i L.LE, M ia P' V-E .i c:c W 1 TP Ti-i(= St DE L.IE-lE KNOTTY UI GE !�►.�� SCTt3hC1C R�gUtaZ>=Nlcujs 01= 2 3 DA-r L= 'L/4/� �wG•� Cl � '� 1.o Y S cZEG15;L�Z�D "WED . Sli2v�`(oVS I Tt-AIS QL-M-1 i•5 +.. 07 L-5ASE'0 Ok--k 4W cis ��evtr_�r_ tiCa.ss. -TkC-- Gi=G�ici S St�cl.l1:U tJC.T L3� USCp 'ics C7CTE�/Vli�ll= LC:'T L11.4%a5 AP�'t_lG/�.tJT_ ! GAPS WIDE -1>=�/. G o