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HomeMy WebLinkAbout0067 JOYCE ANNE ROAD - Health 67 JOYCE ANN ROAD, CENTERVILLE A= 209119 III ® �14p£CYC(FpCpy� UPC 12534 No.2'_R .ro � HASTINGS,MN A =rA n, rl f, 2 = f13 i l f'O1as•INDOWS AND SLIDER TOtED FROM EXISTING 3J IMA EXISTIN EXIST SEASON �s2 NEW ANGERS OR EO. ROOM BATHWROOM EXISTING atluoows TO,}i t GARAGREMAIN REMAIN TO O REMAIN ea CD FAMIL 3 NEW ANDERSON OR E0. ROON ' WINDOWS NEW HEADER PAD FLOOR TO 8 I O 5 FLUSH WRHT ^ EXISTING FIRST I ARCHED OPENING FLOOR I WITH COLUMNS 'VFY LOCATION` - 6 BENCH SEAT WITH UO TO CONCEAL WATER METER I LIVING -.. _ WINDOW AND DOOR SCHEDULE: I I — ROOM TAG ME FINISH BRAND MOBIL NOTES REMOVE OR COVER EXISTING - :O I I' DIET ' 1 TXI•BAY WHITE PA BRAND MODEL NOik4 SNYLAHT _J I I ,....,. ., 2 26CICRCLE WHITE P/F BRAND,' MODEL NOTES 3 2-BX416H WHRE P/F BRAND MODEL NOTEi POTENTIAL SEWER LINE 4 28XVB OH WHTTE P/F BRAND MODEL NOTE- LOGA{ION 5 raX4'8 ON WHITE P/F BRAND, MODEL NOTES 14 _. . [U, 7/B• 6 28X4'8 OH WHITE P/F BRAND, MODEL NOTE$ 15'4 [ 2 �I— —�'J DINING T 2BX4'8 PH wHFTE Ff BRAND: MODEL NOTES ,• NEW 3'CIpGULAA WINDOW O I I j 15 2NEW DOUWNDOWS 8 2B7(4re FIN WHITE P/F BRAND. MODEL NOTES I WINDOWS 9 51X689LIDER W/P/F BRAND MODEL N ' 10 2'BX/99H WHITE P/F BRAND MODEL NOTES EXISTING WALL TO REMAIN "'. 11 2BX4'80N WHffE Pff BRAND MODEL NOTE ++ d'"NEW WALL 12 2BX/1 DN WHITE P/F BRAND MODEL NOTEI; 17 1 13 28X4'0 dH WHREPF BRAND' MODEL NOTFf 13'11 14 2BX4.4 OH WHITE P/F BRAND MODEL NOTES KITCHEN '� 2 VERF OOWMN AND RAILING COVERED '-2NE OU LE HANG LOCATION 16 28X4Yt]H WHITE P/F BRAND MODEL NOTES C' NDOWS 16 28X4'4 d,H WHITE P/F BRAND, MODEL N § PORCH a a 17 28X4'4 FIB wHIFE P/F BRAND MODEL NOTE 1 1ST FLt OR PLAN T .......... OPTIONAL BOX BAY WINDOW 4'-61SIS' 9'-6 3/4• .. 9 9 a 3 �`FLR LuG r� L uKC. Arc�ff��oob� BuHda(F��67 J�YC AN N E LAN E pL a(tm �,�Pomp 1910��RPd.v�®o�,1��0e 2157512 CENTERVILLE,MA L ` - � � -- deck shave.. ✓�'k sltdna ama of meter aulm ed '.master - eras r iir ezared .. .. UnUNsh a r IOW e celRon aUic Unnnlshed LOW cell mlh FF a p msr4Ye wiLLlo mwsr o rouwemm �Bed�oom 1 SECOND FLOOR,LAN AX 3/I6'=P-0' 61-1 11 81-33/411 BRYCE'S BATH L_ ....-..... 1- T M - - NEW MASTER ATH _ . . .__..� - - -- _.. - ---r- --- ,-- -- 1 - -- ___[ _ -�- --[--- -- 1---, -- - 14'-81/411 Y L 1m L � O C [o sit Q�d LsCtA i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: / key to move your cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Environmental „y Company Name 43 Triangle Circle Company Address Sandwich MA 02563 Cityrrown State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at thisaddress 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. 1 am a DEP approved system inspector pursuant to Section 15:340 of Title 5(310 CMR 15.000).The system: %J, • ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �.a �'v4 46" «4, K S February 18, 2011 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and-copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future udder the same or different conditions of use. l W`ins-09= Title 5 Offidal Inspection Form:Subsurface Sawage O posal System•Page 1 of 17 E Cominnonweafth of Massachusetts Tiffe 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not.for Voluntary Assessments. tiw_ 67 Joyce.Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C',D or E./always complete all of Section D A) System Passes:. ❑X 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria listed in section D or E (pages 4-5)..The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health; will pass. Check the box for"'yes", "no" or"not determined" (Y:, N, ND) for the following statements. If"not determined;"please explain. The septic tank is metal and over 20 years old*"or the septic tank (Whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): z 15ins-09108 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'Y 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.gg/pg Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow 15ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments «� 67 Joyce.Anne Road. Property Address Ernest and Ruth Corbett Owner Owner's Name information ie Centerville MA 02632 February 18, 2011 required for every ry page. City/Town State Zip Code Date-of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last.year NOT due to clogged or obstructed pipe(s). Number of times pumped ❑ ❑X 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 portionof a cesspool or privy is within a Zone 1 of a public well. ❑ 2 Any portion of a cesspoolor privy is within 60 feet of a private water supply well. ❑ E Any portion of a cesspool or privy is less than 100 feet.but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates.absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ❑ 10,000gpd. 0 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 10000 gpd to 1,5,000 gpd. For large systems, you must indicate either"Yes"or"no to each of the following, in addition to the questions in Section D: Yes No ❑ ❑ the`:system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary,to a surface drinking water supply ❑ ❑ -the system'is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered "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 31:0 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 15ins•'09me Title 5 Offidai-Inspection Form:Subsurface Sewage Disposal System Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18,2011 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided b the owner, occupant, or Board of Health P 9 P Y P ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 310 CMR 15.302 5 PP P )[ Ol D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN,flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd n L urn,09J08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name. information is Centerville MA 02632 Februa 18, 2011 required for every ry page: City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes © No Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes Z No Laundry'-system inspected? ❑ Yes ❑ No SeasonalusO ❑ Yes Q No Water meterreadings,.if".available (fast:2 years usage (gpd)) 40:: —gpd Detail: 2009, 2010 Sump pump? ❑ Yes ❑X No Last date of occupancy: about six weeks ago Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310,CM 15.203) Gallons per day(gpd) Basis of design flow(seats/personslsj,ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•M08 Tide 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information at on Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Age 28+years. Design plan dated 5/19/1982 (Building Dept. files). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Sewer line is under concrete slab and not accessible for inspection. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5ftx6ftx5ft(1000gal) Sludge depth: 4 in t5ins-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 In Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time but maintenance pumping is recommended within and every two years. Tank appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09*8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No ,Sins 09= Idle 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is Centerville MA 02632 February 18, 2011 required for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert at 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.): Few solids in sump. Distribution box appears structurally sound with no staining into structure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•0901 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed.A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly into the leach pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins-09= rdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is required for every Centerville MA 02632 February 18, 2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Ownees Name information is required for every Centerville MA 02632 February 18,2011 page. City/Town Stale Zip Code Dale of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: © hand-sketch in the area below ❑ drawing attached separately 5eptic rnN� 311 zI A CE�r � . -- a7 Pr, o L- -F Z f7 'k joy(E RwNC FIND 3 ISvts•09108 Tdle 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 'Commonwe_ alth of Massachusetts Title` 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is Centerville MA 02632 February required for every 18,2011 page. City/Town State Zip Code- Date of Inspection D. System Information (cons:)` Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells . Estimated depth to high ground water: 25+ ftfeet Please indicate all methods used'to determine the high ground water elevation: ❑X Obtained from system design plans on record. If checked.,.date of design plan reviewed-: pate. ❑ 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_) 0 Accessed USGS database-explain-, Barnstable GIS Department records You must describe how you established the.high ground water elevation; Approved design plan on file shows bottom of soil absorption system.to be 4 feet above.the bottom of a witnessed test pit in which no groundwater was observed. Town of Barnstable G15 Department records indicate that the property is over 25 feet above groundwater table Before filingthis Inspection'Re,Report,. lease see Report Completeness Checklist on next page. p p p p p 9 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts - � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 67 Joyce Anne Road Property Address Ernest and Ruth Corbett Owner Owner's Name information is Centerville MA 02632 Februa 18, 2011 required for every ry page. CityFrown State. Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked. Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins-09108 Title 5'OKcial Inspection Form.Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION APJ iyE 1�0r4 O SEWAGE# VILLAGE C60T E F-V I(L C ASSESSOR'S MAP&PARCEL 2 01 A Iq INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 0 � LEACHING FACILITY:(type) P� (size) 1000 1" ,NO.OF BEDROOMS 3 OWNER PVT PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist .on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY TCIC 4 - 1 M5RCC¢;On Z -201 Sev��c TTVQ 3p 2 R ' 0-i3nx L7 a13 Z C �1 (0 `lZ DYC� RNNC `�6A D Commonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection AN One winter Street,Boston,Ma. 02108 Jolui Grad D.E.P. Title V Septic Inspector P.O. Box21.19 Teaaticket, MA 02536 WILLIAM F.WELD `50 1- Governor ARGEO PAUL CELLUCCI Lt.Governor 4u' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMI EvEO PART A 1.LL1YI. CERTIFICATION t NOV 1 3 1998 Property Address: 67 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 Address of Owner: TOWNOFBARFISfAM Date of Inspection: 10/19/98 (If different) KWHDEPT. Name of Inspector: JOHN GRACI COLETTI;21 COTTAGE LANE CENTER I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x_ Passes This Inspection Is based on criteria deflned In Title V _ Passes code 310CMR16.303.My findings are of how the system is Conditionally performing at the time of the inspection.My inspection does _ Needs rt er Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fails septic system and any of Its components useful life. Inspector's Signature: p Date: 1o/91/98 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not►netal, is cracked,structurally unsound, shows substantial infiltration or Wiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 Owner: COLETTI;21 COTTAGE LANE CENTERVILLE Date of Inspection:10119199 _ Sewage backuQ or.breakout or hioh,static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 67 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 Owner: COLETTI;21 COTTAGE LANE CENTERVILLE Date of Inspectlon:1or19198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 JOYCE ANN RD.CENTERYILLE MAP 209 PAR 119 Owner: COLETTI;21 COTTAGE LANE CENTERYILLE Date of Inspection:10119199 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of aces 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 Owner: COLETTI;21 COTTAGE LANE CENTERVILLE Date of Inspectlon:1011919a FLOW CONDITIONS RESIDENTIAL:Design flow: 330 g.pd./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: 1 WEEK AGO COMMERCIAL/INDUSTRIAL: Type of establishment: nin Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: n1a Last date of occupancy: n1a OTHER:(Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1000 gallons Reason for pumping: MAINTENANCE TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: SYSTEM IS 16 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no) No (revised 04127,97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 07 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 Owner: COLETTI;21 COTTAGE LANE CENTERVILLE Date Of Inspection:10r19198 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate metal_FRP_Polyethylene—other(explain) If tank is metal, list age nra . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le a°H6-T--W4-1O-- Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 15" How dimensions were determined: MEASURED Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: rva Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rva Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumpingn- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rVa BUILDING SEWER: (Locate on site plan) Depth below grade: 2-6" Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction llne:TOWN Diameter: nla rTveimments: (conditions of joints, venting,evidence of leakage, etc.) (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 Owner: COLETTI;21 COTTAGE LANE CENTERVILLE Date of Inspection:10119199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metai_FRP_Polyethylene_other(explain) Dimensions: nfa Capacity: nfa gallons Design flow: nfa gallons/day Alarm level:_nfa Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: LIQUID LEVEL WITH BOTTOM OF PIPE. Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) DISTRIBUTION IS STRUCTURALLY SOUND PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) n!a (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 Owner: COLETTI;21 COTTAGE LANE CENTERVILLE Date of Inspection:10119198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number:Na leaching galleries, number: Na leaching trenches, number,length: Na leaching fields,number,dimensions:Na overflow cesspool, number:n1a Alternate system: Na Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAD T OF WATER IN IT AT THE TIME OF THE INSPECTION,IT HAS NOT HAD MORE THAN 2'OF WATER IN IT. CESSPOOLS:_ (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY: (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na )revised 0412197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 67 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 COLETTI;21 COTTAGE LANE CENTERVILLE 10/19199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) g N A ),.A e ° i� 0 7 Bc 3q r. (revised 04127197) Page ! of 20 l r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 67 JOYCE ANN RD.CENTERVILLE MAP 209 PAR 119 COLETTI;21 COTTAGE LANE CENTERVILLE 10119199 Depth of groundwater 12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised04127197) Palo 10 of 10 New Floor Joists 2x10kd Wo.c. 0 ON Instal R-30 Fiber lass II nsulation DECK Install 516 type X 9recode sheet — — — — — — 16_1%4' rock on garage side of ceiling / I Hobby Room \ 4 GARAGE � - MIL 3-1 514cM4"ganged together Simpson Joist Hangers per code. I Existing Floor Joists 2xbkd 16 o.a. 16'-0' Hobby Room Over Garage Floor Framing (Front Joist Exisitng Rear Joists New) Date: 10-25-2002 PAGE Home Improvement Specialists of Gape God Inc. 61 Joyce Anne Rd. Scale: 1/4"= 1' 25 lyanough Rd. Ph.508-115-2815 Centerville, Ma.02632 Designer: p 3. Hyannis, Ma. 02601 Fax.508-115-2881 6 TOWN OF BARNSTABLE LOCATION CP SEWAGE# V,�-,.LAGE ASSESSOR'S MAP & LO?--Oq—( INSTALLER'S NAME&PHONE NO. fI SEPTIC TANK CAPACITY Ulu LEACHING FACILITY: (ty, ) I�t �1 _ (size) 1®o U NO.OF BEDROOMS o BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 11 /3 M 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 yA1 ,rrIM THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................... ..:................OF.......................................................................................... Appliration for Uhipaii al Work.6 Tnntrnrtion runfit Application is hereby made-for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: o T 20 _ cl Joyce Qs3ti1a R® - aJmpm utl -- . ............_ ........-------•-- .... ..----...••-----•_..._ .----------- Location-Address or Lot No. .... 3 �D— v..l�c. W dress G - e 7T n^C�L �.l �..............• �i� L,.. ] e Installer Address Type of Building -W OpD FZA M* •' P_C-SiJb C-0e_C" Size Lot...............:............Sq. feet U Dwelling—No. of Bedrooms.•....-2.....:...........................Expansion Attic (+:-) Garbage Grinder (No 'k Other—Type e of Building No. of ersons....;................... Showers f� YP g ---------------------------- P (o) — Cafeteria ( ) a' Other fixtures ............................... ... W Design Flow............5_.,7�-......................gallons per person,per�day. Total da}ly flow---:-?-0.4.............................gallons. WSeptic Tank—Liquid capacity W®Q.gallons Length............. Width_........... Diameter................ Depth. _..._.... x Disposal Trench—No. .......:............ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I............ Diameter.._....6.......... Depth below inlet......a......... Total leaching area_zd D.......sq. ft. Z `Other Distribution box ( ) Dosing k Percolation Test Results �� Performed by 't-•----- Date aTest Pit No. 1......02,0----minutes per inch Depth of Test Pit...1.1ti___....... Depth to ground water-___N.. C--- . Test Pit No. 2.`- A¢mfinutes per inch Depth of Test Pit__-_-_-_•-..___--... Depth to ground water........................ P4 . .... ------------ 4..............................................-------•------••••-•-----•--•.................•......... O0 - ---- Description of Soil.----- -�? 'P'1.---- - -� ;W.......L----------------------------------•------•-r--------------------------------•--•----•----•------------ x ..........A-------------------------------------------------------------- M ---- U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. •-•-----•---------•---------•--------------•-------------------------------•---•---------•--------------•--------------------------------------------------------------------••••••-••-••......---...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be# issue by the board of health. Signed-• 0 - •••----• •--•- -•••••.............••-•-........ ..;y----•---•-----------•--._....-•-----•-----••--------- Date Application Approved By...- .._.�-!��� ........................... Date Application Disapproved for the following reasons:_...----•-----•----------------••-•------•----------•--•---•-----•-•-•-•-•-----------•-----•••............-•---- ..-••-•-•-----••••••---•••---•••••---•••••-•-••••---••••--••-.....---•----.....••-•-•--------•••-•••-•••....•---•-•--••...--•-----•--------•--------------------------•----••--------------------------- Date PermitNo......................................................... Issued-....................................................... Date S N,, 6 2-2-.5�? FEs......:��............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................O F........................................------------... Apphrtttiun for Mipoiitti Work.6 Tongunrliun amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ j) jjyy� J .~...............�........�.. ,�-..+ i"1..�f..¢.ul... _.. � t ................ .................._ .......................................... Location Address or,Lot jo .......... .��--"__.... ''.... ._. .J.._•--•---^•....................^_.._.. ._......................................... ._.. ..- ........_..-... _........ Owner Address � Installer � Address dm d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..........4................................Expansion Attic ( -) Garbage Grinder (� } Other—Type of Building ............................ No. of persons........:._._.__.._._--____ Showers ( c ) — Cafeteria ( ) a . Other fixtures .--.---------------------------------------------------------------------------------------- W Desg �I `F a g P P P Y Y - � ...gallons. ign Flow.............yf.... .._...._.............gallons per person per day. daily flow____. .-�........................_. WSeptic Tank—Liquid capacity.f��.�_0gallons Length___._6. ._.... Width-.<f....._..._. Diameter................ Depth... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........f----------- Diameter....... ;......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing t nk ( ) Percolation Test Results Performed by-------- `_'_C .... Date...... Test Pit No. 1........ '...�minutes per inch Depth of Test Pit.... _......_ Depth to ground water------ ` .'�. ' "`� Test Pit No. 2._._..:�:Mkmutes per inch Depth of Test Pit.................... Depth to ground water........................ l--••----------------------------••--------••......................................................... A /- �':_... ____________________________q...----_----_-..-.-.--.___.-.-.-..-.-------_•---..------_.O Description of Soil....... W UNature\of Repairs or Alterations—Answer when applicable.........................................................:...................................... 1 ----------------------•-----.....---------------•--------------------------..........---........--•----•----...--------------------------------•----•------------------------------------------•---•-•-• Agreement: The--undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y the board of health. 4. Signed___.. Date , �j --•y---'--•---'------------------•--------••---......--- Application Approved BY----:-� P_. e....-'' '-••------------------------------------- I Date Application Disapproved for the following reasons:........................................................................ ............. ---------------•----.......-•----•--------•-------....---------------•-----••------------......---------.._.....--------...------------------------------------------------------------------........... Date PermitNo.......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................................:.OF..................................................................................... �rr#ifirtt#r of f�unt�gittnrr THIS"IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....................... ---.-..--------------------•.--...-.--•--•-•----------------------.----------.------•---------•-------;---------------•------•--•-•-•-•---------------•--- ,,,,, /? Installer , `� has been installed in accordance i tlsions of TIT�LiE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit ........ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.DATE.....................................I'L- --2............................. Inspector............?/Z)--/ �-•----•-----------•---•-------•------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................0 F..................................................................... .... "' No... ... �? FEE...-t............ Disposal u� Tunutr ion rrntit Permission is reby granted ....4 ^��"--"-----------------------------•--------------------•-------•---------------------------••--------•-•--.....---••-'-- to Construct ')or Repair ( an Individual Sewage Disp sal System at No. cam- - _.... .. � ----------- Street as shown on the application for Disposal Works Construction Permit No....................• Dated.......................................... - .......... �--�' y______._... .... -------------------------------- / Board of Health Lb Z DATE. ............................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �>=�5 t C►mil TjQ,T A radt►-Y F'Low � Ilb � .� + 330 G•P•D. ' �v l5� ��-t c `ram k = 330,, l5 0 % • 4•�i 5 6.P ,� use- t ocoo 6aL.. lG'`I So � 2'j15PO5AL PiT - u5E l o00 �a�. 3G:t .,Ur= ALL AZEA = (50 1c"o G.P.D. p 'Bd'1 AA ,OQEA r� ST=: i SD TOTAL -C>eSI6" = 425 G.P.D. I TbTQL mat��� Flow - 33D b.t?D. •' J ° � GMdGDLQT%o L.I zwre C it.) 2M t u' 0 1 z Lk.S<,. M -R 4 I M/A/ t � ' `J° ;q Tor P-40 4 LOan/ pe loon 1w ',+ S✓6SoiL 4'Pve iw. G e L. 97.8 2 IWV. 'box q74 T. Io ?: i.p -jAe7 M ' j 4 I�o0 7•0o iW c. V LA�EaZS LEgcN Q7 Z 97 o� FIT 1 SA�oy Wrrw 4 I GRA�c. !a/4 WAS►IED 1.06be PRp�'tL� LOCAT1OtJ CEIJT V.IL�� 2 v o lr. a E 3� L � iL 40 3�a-r e= S/Iq o?_ do Wai�R. I GGtzTtt=Y TO-lA-r Tt4t— I cLADATI014 5Now ��--At..l R ctZi~►.1GE t-lF:t`Lbt,1 Gc �PI.�IS W VrA T► ;Z: SIDE. WF_- L.T. 20 AWL7 '5E71'.ALI4 V:C-gcJit eAA&WTS of T14E -TowU or A2�.151'A8 Pc-• a1C 3 I S p. 2Z- RCGIS•t'CRGD LAwo Sue_Va'(ov-< TMlS C7LA1-1 1!, ►JOT b.SCt7 vt^-! A�.I OSTE�L�/1t_�G o MASS. It.ls('e:Jl✓�t_w� �,ut:.it-�{ � T+�L UFCS�T�, St•�cwuO AF�At...t GA.t�IT V,br car_ cJ�,e�� Tc, tac�rcetil�►JL'.: �oY' t_tw�� � 6L-eT_r _ p1=�tE►�l �Q,TA SLr,JGLe- t=&M%L.>-� Q0 ,GAm7RAAd-- 6-wl . . " T ►L.�! FL�w r- tto +c -3 + SS0 G.Rt7. " Zv t5-� �t_Qt-t c -r4"k = 330,E ISo % • dui 5 6.P. � USA- L o0C, 6Ac.-. i(ol�So 1715Po5AL PrT - uSr= loco GAA-. t S,tTEWALL ALZEA = 15o I� SF ,< 2.S S77S G.P.D. p SO ,4 TOTAL -C�ES16W c .4.25 G.t?D. � ` 1_ �•wK 0/, � 'rbTAL_ �,dt L_�f FLOW - jw 6.PD. J p�P �•o�•� VE2GZ7LQTL0L.J CZQTE :• qg,s �— otq j M /1 M/N �•y v: •teec •Jt �µ of Ai..•,ry dFY.+• :"...., .._r: y;� � . ./•. 11.E � p w� P. `� '(-:.°•��r. .;/,'�'rya. �1 /�;'/ 'T'ESl" P`23v 3-18-8/ /LG - a- Smog,�• tuN.`9Bo 17-a '�a� a►sr Iw. GAL. q'1.8 Z v 't3ox �T1e: Tice >� 1000 ,���, %w s• 974 Pa e-_ L,4�Ozs L% c 4 , or PST ; W1*rW I 1 a/4"-I'/i ; . 6qa mac. 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