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HomeMy WebLinkAbout0103 SEAN'S CIRCLE - Health 103 Sean's Circle Centerville P A = 170 057012 UPC 10259 Ft No. H1630R I Commonwealth of Massachusetts L w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �Y ,M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 r Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 ,5 page. City/Town State Zip Code Date of Inspection taa 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 �v 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 Rapid Response t� Company Name 155 George Ryder Road South Company Address Chatham MA 02633-1621 City/Town 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 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 jH OFElConditionally Passes ElFails ' ❑ Needs F r EDV do he Local Approving Authority D. COUP N WR N 13 8 4 a»�, March 15, 2018 Inspector's Signal TF�fNSP Date The system inspec 11 submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***`This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ).W o 'Commonwealth of Massachusetts r W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chap rales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: . ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and 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 thels'epticitank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltratlon?or�-tantC.tallure is imminent. System will pass inspection if the existing tank is replaced with a'c"o plying'reptic",tank as approved by the Board of Health. P* it t CI .Ar'VVQ�A# DU0 ) , A metal septic tank will pass inspection if it is.- tsound> not lea king and if a Certificate of Compliance indicating that the tank is less than 20 ,ea'rs:old:;=stava,llable. ElY ❑ N ElND (Explain below):' t ' t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 FIND (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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r II Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: _ Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is Centerville MA 02632 March 15 2018 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El Were if the Were as built plans of the system obtained and x ( y were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a-no plan t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is Centerville MA 02632 March 15, 2018 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 407 gpd 9 ( Y 9 (gpd)): Detail: 2017: 137,000 gallons 2016: 160,000 gallons Irrigation system in use Sump pump? ❑ Yes ® No Last date of occupancy: 1 month ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is Centerville MA 02632 March 15, 2018 required for every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 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 unknown—system is assumed to have been installed at time of dwelling's construction in 1979. No file at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line 10+: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): Depth below grade: 0.5 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: 8.5' x 5'x 6-1000 gallon Sludge depth: 6 inches t5ins.doc-rev.6/16 Title 5 Official Inspection Form: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 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. CitylTown 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 28 inches Scum thickness 2 inches Distance from top of scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 13 inches How were dimensions determined? previous inspection report 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 not required at this time. Maintenance pumping is recommended within 2 years and every 2-4 years thereafter with year round occupation. Tank and tees appear 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 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.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. CitylTown 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of 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 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 —page ---City/Town-------------------- -- ---- State---Z-ip-Code------Date-of Inspection- D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately SEPTIC INFO AT -OF SEPTIC COMPONENTS E C O S E C H,U S -DISTANCES IN DECIMAL FEET A B 1 24.5 lm 2 1925 1B 3 1635 I'M 4 3V 2,1.5 LEACH PIT 1000 GALLON SEPTIC TANK B ]�2 D—BOX A pp�� v� EX I S UN G THIS SKETCH IS BEST VIEWED IN WELLING COLOR FORMAT r Q NOT z TO SCALE SEANOS ORCLE 508 364-0894 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 103 Sean s Circle Assessors Ma ,M . 170 Parcel: 57-12 p Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 15 feet above groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 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 ;M 103 Sean's Circle Assessor's Map: 170 Parcel: 57-12 Property Address Arthur G. Chaprales Owner Owner's Name information is required for every Centerville MA 02632 March 15, 2018 page. ---City/Town---- -------------- ---State----.Zip Code---- ---Date-of-Inspection---------- _ E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE — NOT TO SCALE { II9 11 11 10 1 T 11) /1 /P PRECAST g LEACH PIT + BOTTOM OF LEACHING FIT LEACHING IS ABOVE HIGH GROUNDWATER i GROUNDWATER ELEVATION PER GIS MAPS t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 J i y COMMONWEALTH OF MASSACHUSETTS 4 W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION yA� b�bv TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 103 Sean's Circle Centerville MA 02632 LAU co-A Owner's Name: Donald Girard t Owner's Address: Same - '1 C)s,71 Date of Inspection: October 4,2007 Job#07-222 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD 1 MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CD rn C5 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: )S Passes _— Conditionally Passes __ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 10/4/07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Tank is not in need of pumping at this time,liquid level in leaching pit was 30"below inlet at time of inspection. Distribution box was found leaking and was replaced for inspection. ****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. Page 2 of 11 OFFICIAI, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1.03 Sean's Circle,Centerville Owner: Donald Gerard Date of Inspection: October 4,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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: Page 3 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1.03 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 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 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 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: i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 103 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ 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. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—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. Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 103 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X Were any of the system components pumped out in the previous two weeks? _X _ Has the system received normal flows in the previous two week period? _ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X_ _ 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 _X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ 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)] ' Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 103 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents: I 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): Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Two years total: 56,000 gal.=76 gpd. 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/sgf4,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: 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 _X_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: 1980's Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 103 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 BUILDING SEWER:XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron X40 PVC_other(explain): Distance from private water supply well—or—suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_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:8.5'long x 5.2'wide—1000 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank has liquid only,no solids.Liquid level was found at bottom of outlet invert tees are intact and clear. GREASE TRAP: No (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.): i Page 8 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 103 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 TIGHT or HOLDING TANK: No (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: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Box w_as found deteriorated and leaking. Box was replaced for inspection PUMP CHAMBER: No (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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 103 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. 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.): Liquid level was 30"below inlet at time of inspection with a hieh stain line 1'above current level CESSPOOLS: No (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: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 103 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 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. Sean's Circle Water Service Kxb- 17 21 47 0 29 51 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 103 Sean's Circle,Centerville Owner: Donald Girard Date of Inspection: October 4,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 15 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: _Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.35 and topo map shows property at el.50. 1 Town of Barnstable OF tHE Tp� Regulatory Services Thomas F. Geiler,Director • BARNSUBLE r f y MASS. $pTE16 9. Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE LOCATION f®3 A✓1'b (2,rc Lt SEWAGE �I #�✓t%P VILLAGE ( y1+-trvALZ ASSESSOR'S MAP&PARCEL INIRWIMM NAME&PHONE NO, nc.k. CIL evqlyu l SEPTIC TANK CAPACITY 1 a00 LEACHING FACILITY:(type)" 111- (size) 0100 �P NO.OF BEDROOMS ee OWNER 0 'r�.r�` PERMIT DATE: CI I E DATE: /0/q G7 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 1-00-1 Sean's Circle Water Service 17 21 47 0 51 29 No. O�Od Z/ 3 Fee l a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mi5pozat *pgtem Congtruction 3permit Application for a Permit to Construct( _ )Repair( )Upgrade( )Abandon( ) O Complete System Vindividual Components Location Address or Lot No. I D 3 Se C.1 f1,5 Cl rG1 Owner's Name,Address and Tel.No. Cen4e�(tl� won Cqt�arp Assessor's Map/Parcel , 1035 E i n Clr W 0.5 ®� 508-98Ti -n D58 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. IRDbeeT UILvoy -3tG Excava 1(on 14 Tectbea�y Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Ce aLE> - -OPJ0± Q r\ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of tl e­afore 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 issued by this Board of Health. Sig Date 10 7 Application Approved b Date Application Disapproved for the following reasons Permit No. aQ0 7--IV S3 Date Issued 0 No. 00 I "7 Fee a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes P,UBLICr HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS -1ppYication for 0iopool *pMem Cottgtructton Permit Application fore ermit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System dividual Components Location Address or Lot No. 10 3 t2 f� `a ` G4it Owner's Name,Address and Tel.No. Assessor's Map/Pazcel er"0e. Ceni1 -Don 61 1rnr p � DS ©/ 103 5eCnn'.5C,r 1� 50S- 98q- UU5 Installer's Name,//Address,and Tel.No. Designer's Name,Address and Tel.No. LT-&\/ - BIG t X( CI VC.-j tG() Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 issued by this Board of Health. Sig e , Date 10 Lj 10J.. Application Approved b Date 6 Application Disapproved for the following reasons Permit No. -7--y,!513 Date Issued D r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ✓)Upgraded( ) Abandoned( )by F v ✓e, 4 p at 10-7) C)P LIJ1 /" t rF t - i t I Q has been constructed)n of cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �M_"7-- 5 ted ` / 7 Installer/ ,(7 T L 1 l T f t t Designer The issuance of this permit shall nabe construed as a guarantee that the syst m Will,fun ton d designed. Date Ali ` �'?'') Inspector � - ` / .No. �t� —'7 S Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopo$af *p$tem (Cottgtructton Permit , Permission is hereby granted to Construct( )Repair( w)Upgrade( )Abandon( ) System located at 1 f � e r 7 � �y I I t P `. . and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust a completed within three years of the date;af this� rmit Date:_. �� Approv;d H t ECOJECH Environmental www.eco-tech.us THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVE® Property Address: 103 Seans Circle Centerville Owner's Name: Eileen M. Wolf NOV 12 20OZ Owner's Address: P.O Box 182 Centerville,MA 02632 TOWN OF BARNSTABLE Date of Inspection: November 7, 202 1HEALTH DEPT. Name of Inspector:(Please Print) David D. Couuhanowr,R.S. MAP 8 I 1-7 fl Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle PARCEL 0 S� 6 1 2 Sandwich,MA 02563 LOT Telephone Number: (508)364-0894 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: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature I`MM4 Date: V60 7, ZdO� The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority NOTES AND COMMENTS Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. 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. ****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: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7, 202 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 5.303 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,or 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 breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The 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 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 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: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7, 202 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 and 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 by 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: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7, 202 D)System Failure Criteria applicable to all systems: You must indicate either"yes" or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described 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 X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X 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 groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X 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 by 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7, 202 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant or Board of Health. X Were any of the system components pumped out in the last two weeks? X _ Has the system received normal flows in the previous two week person? X Have large volumes of water been introduced to the system recently or as part of this inspection? n/a _ Were as built plans of the system obtained and examined?(If they were not available as N/A) X _ Was the facility or dwelling inspected for signs of sewage back-up? X _ Was the site inspected for signs of breakout? including X _ Were all system components,exeluding the SAS. located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum.? X _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: X _ Existing information.For example,Plan at the Board of Health. X _ 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: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7, 202 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no records on file at BOH Number of current residents 1 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no):no :(If yes, separate inspection requiredl Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two year's usage(gpd): 97 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sqft/etc.): Grease trap present: (yes or no) Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no). Water meter readings, if available: Last date of occupancy/use:_ OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS source of information: System not pumped in recent past(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: X 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/Alternate 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: Age: 23+years Certificate Dwelling constructed in 1979.No records on file at Board of Health 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: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7, 202 BUILDING SEWER_(Locate on site plan) Depth below grade: 1.5 ft Material of construction:—cast iron X 40 PVC other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting,evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK: X (locate on site plan) Depth below grade: 6" Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000gallon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle: 30 in Scum thickness: trace Distance from top of scum to top of outlet tee or baffle: 10 in Distance from bottom of scum to bottom of outlet tee or baffle: 14 in How dimensions were determined: Probe to top of tank 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 not required at this time but maintenance pumping is recommended every years Liquid level at outlet invert.Tank and tees appear structurally sound and functioning as intended No evidence of leakage in or out 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: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7, 202 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 inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: X (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 is equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.) D-box appears structurally sound with no evidence of leakage in or out Effluent level at outlet invert No solids in tank. 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 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 103 Scans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7, 202 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan;excavation not required) If SAS not located,explain why: Type: X leaching pits,number 1 _leaching chambers,number _leaching galleries,number _leaching trenches,number,length _leaching fields,number,dimensions _overflow cesspool,number _innovative/alternate 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 leach pit appeared unsaturated.No evidence of surface ponding breakout lush vegetation, or other evidence of hydraulic failure was observed.Leach pit contained 14 inches of effluent in a 6 ft pit CESSPOOLS: none (cesspool must be pumped at time 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: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7,202 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'(Locate where public water supply enters the building) LEACH LOCATIONS PIT O A B 1 24.5 ft 10 ft 2 19.5 ft 16 ft SEPTIC 34 D-BOX 3 16.5 f t 25 ft g TANK 2 4 30 ft 2 7.5 ft I A 2 BEDROOM DWELLING J Z J W H G 3 I II SEAMS CIRCLE NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 103 Seans Circle Centerville Owner: Eileen M. Wolf Date of Inspection: November 7 202 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 19+ feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed X Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: _ Checked local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Town of Barnstable GIS Department records indicate that the Groundwater table lies over 19 feet below the surface of the lot.Appl inng a groundwater adjustment of 5.3 ft. (Index well SDW-252 Zone D October 2002 level=48.0 ft) demonstrates that the bottom of the SAS is above adjusted high groundwater 11 TOWN OF BARNSTABLE LOI ATION _ �'J Sams Ct r'C.k'£ SEWAGE # YII.1_aP►GE C�n��C y c I �� ASSESSOR'S MAP&LOT -.obe--r 6.11L Dy- �t-d FKr-av&+ion INSTALLER'S NAME&PHONE NO. 5 nA- ►+-11-IV) (0 5 B SEPTIC TANK CAPACITY LEACHING,FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: k 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 leaching facility) Feet Furnished by I�DuJ ff De T hK �'Ok No.------------ ............ THE COMMONWEALTH OF MASSACHUSETTS BOARDM'�-PF' HE ..............OF... .................................................................................. Appliration-for Di-silos alWorks Toustrurtion Prrutit Application is hereby made for a Permit to Construct (L,<aor Repair an I ividual Sewage Dispq# System at: ................... ...... ............... .. Lo o - dr s t No. ............. .. ....... -------- ....... ---------------- ------------- 21-Y- ZJ............ ................ ......... . .......... .. .. ........................... ............. ........................Y.......... ,,e 7 ner 7 Address Installer Address Type f uilding Size Lot_._. ......Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons...._................._.___. Showers Cafeteria PL4Other fix�ts .................................................................................................................. ................................... Design Flow................ gallons per person day. Total daily flow------------2414 M. ....................gallons. Septic Tank—Liquid capaci ---- --------- r a ns Le n g ------ Width.___ . ... Diameter________________ Dtaith................ Farea------3 2 Disposal Trench.—No4��. T talleaching . _—sq. ft. Seepage Pit No..................... Dfamdter-_---_----------- Depth below inl t.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutesperinch Depth of Test Pit___.__.........._... Depth to ground water_._.____...._........... Test Pit No. 2................minutes per inch Depth of Test Pit.__.........._._.... Depth to ground water._-_._..............___. • -------------------X................ ........ ----------------- 0 - ------------- .. .....................Description of Soil----Z' I------....... -------f e ....... ..... ------------ ................... ............................. ------------------ Nature of Repairs or Alterations—Answer when U ---- -- . . .. ..... A. ....... ................. .................................................................................... . ....... . . ............... .... ............................. Agreement: .-The undersigned agrees to install the aforedes.cribed Individual Sewage Disposal System in accordance with he State Sanitary Cod The the provisions of TH'APIZE- '5—of_t� S o — The ersig d further agrees not to place the sy em in operation until a Certificate of Compliance has b ued b oa, f health. Sign .......... ... ...... ....................... ......................... ........ Date Application Approved By......... . ........ -—-------------------- ...... .. .......... Date Application Disapproved for the following reasons: ........................................................... ................................................... ........................................................................................................I.............................................................................................. Date PermitNo......................................................... Issued.....................................*--------*-------- Date ®r?) No.............. ...... .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD' F H ...................... ...............OF.-. ..... ......................................................................... Appliration for Uispoiial Works Tomaurtion lirrutit Application is hereby.made for a Permit to Construct (t.,�3o�rRepair anI ividual Sewage Disp(�sal System at: ............... ............ ................. .. .......... ...........Ir................................ ---------------------------- t No A5 E*0­ io" ................ ........ ............. ........... .. .. ......... ................ ................. ........................Y0 ................ ner Address ............. . ......... ............ ............................................................................................... Installer—— .......... ...... ... Address , OMType of uilding Size Lot---- --7-7..................Sq. feet Dwelling—No. of Bedrooms...............2..........................Expansion Attic Garbage Grinder 04 Other—Type of Building............................. No.-of persons............................ Showers Cafeteria OtherfiN=s .......... .............................................................................................. ;�t---------------------*.....Design Flow.. _0.................gallons per person pgr day. Total daily flow------ 2............................gallons. 04 Septic Tank—Liquid capacit a o n Len , Width.-it3Z. e& ....p.......... -- ------ ..�. iameter................ D h I Trench—Narea-------.....)4sq. ft. Disposa 0 T otalleaching SC.. Seepage Pit No_____________________ Diameter.._..........._..._. Depth below inlet________.__._._._... Total leaching area..................sq. ft. Z Other Distribution box ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ Test Pit No. I................minutesperinch Depth of'.,Test Pit............. Depth to ground water.._________.__.__.__.__. fTA Test Pit No. 2................minutes per inch D th of Test Pit.................. Depth to ground water.......................... P4 ............. .. ....... ........ ...... .... .......... .................. 0 .j... ..... Description of Soil..... ... ..................... ................ ............................. ...................... . .................. .......... .. . ...................... -- -----_--------- ------------- ­--­--------------------- ---- . . ........................................................................................................................... ..... .. ............ U Nature of Repairs or Alterations—Answer when applicabl . . ... ............. . ..............................................................................:................. ...... .. .. .......... ............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the prop isions of T I T IZj 5 of the State Sanitary Co —The ersi d further agrees not to placeithe sy ern in X operation until a Certificate of Compliance has b s ued b oa of health.' Sign .......... ... ..................................................... ....... .......... .............. Date Application Approved By...................... .... ........ . ............................. ........ ....... Application Disapproved for the following reasons:........... ....... 1 Date . .......................................................................................... ..................................................=­.............................................. ...............................................................................m................. Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD r,2HEALT ... ..... .............. 0 F....... ...... .................. .................... .........01rdifira of Tontpfiattrr THIS IS TO CERTIFY T e Indiv;&1 e XADisposal System constructed `orRepaired by............ ........ -------------------I——----------------------*--------------------------------------- -----------*--------------*------------ at.........................�7............. 7---------------------------------------------------- ------------------------------------------------------****-------------------------------------has been installed in accordance with the provisions of of The State Sanitary Code as d�cribed in the . NO._ - - r/ application for Disposal Works Construction Permit NO. I------------------­------- dated-----4�../--- ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT, BE CON RUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC 1,0N FACTORY.�ATIS DATE............... ..../.V/..../.......................................... Inspector.. ......... ................................................... .... ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEAtT)41� ................OF................................................................................... No..66.... FEE....._.................. t rod rkg anion ramit Permiss ion. .............................. ......... .......... .. ....................................... ,.,�s granted.................. ........ .... to.Construct ( 1� R -ysposal. Sys an ludividual Sei&&�gyj 0...............�cl .................................................................................................. RSe/t as shown on the application for Disposal Works Constructio/nP t I- �.......&�­ Dated.... 7 1?. N ................................... ........ ................. ............... ............................ DATE.......... zg...... ............................ Board of Heal FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 0511 ,_. L.0,C AT ION SEWAGE PERMIT NO. V� L AG E �--� 1/ o I N S T A LLER'S NAME i ADDRESS jc-)4-, j2 /;�v Ito BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED/8/�y .� �� `� .� � o� ,y �� r �'`.� -- r f bh _ � � � � o , � r � � � � 1 �; .. � �i -'S�� LOT 48- ;' TEST HOLE m LOT 3 9 J LY /., , /9 79 /7699 a' - PAUL MCJRRAY- , 7 -/V 5 P6C70R NAIL IN ASSUM, Ln _ /449 30,0 SOBS OIL � . 1 ' - RE5ERVE M A(UlY! SA N D .'S A N D { tJ1s7 Qox LEACH C:,C3'T 47 , �. PROP '• _ '• �r r . . �. /:�. � - . - ►. PROP 4 a � dntvEliRY. GARAGE' 2v.� .L N.'Q 6-)A 7 N CJ 1V TER , - * - '•t•r 'M. Yip �!�-,y * ' � • - A' .. • r3�•i�rnG S Ert3�C� ��CJi,z?�.n%��.� T�' .-,� . � � .S C,q L E• C' '' �0 ' • M1 . . ', - � , , . . � . +, � • •ate i�oo,�S SE P T/C 5 y5 TAM. 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