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Home My WebLink About0030 KENT LANE - Health (2) 361 Rc AMegan load yannis - .., . - 291 128 a a k d 9 b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments J M 361 Meghan Road N.1 h, sV Property Address hwa William O'Neill w Owner Owner's Name .. �+ t information is H annis '/ Ma 02601 2-12-18 required for every y page. City/Town State Zip Code Date of Inspection*? Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms s-/' on the computer, use only the tab key to move your 1. Inspector: cursor-do not Brett Hickey use the return key. Name of Inspector B&B Excavation ay Company Name 374 Route 130 Company Address Sandwich Ma 02563 Cityrrown State Zip Code (508)477-0653 5113747 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: 0-:Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-12-18 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 tiiaf time. This inspection does not address how the system will perform in the future under the same or.different conditions of use:. t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage.Disposal System Page 1 of 17:. . GoIJAtd Vs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 361 Meghan Road Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 : :: 2-12-18 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: System was in working order at time of inspection. 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, notleaking and if a Certificate of Compliance indicating that the tank is less than 20.years old is available. ❑ Y ❑ N ❑ ND (Explain below): s. t5ins•:3/.13. :Title 5 Official Inspection Form:Subsurface Sewage,Disposal System-.Page 2 of 17::.. Commonwealth.& Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Meghan Road Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 page. Cltyrrown 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 breakout 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.wlthin 50 feet of a surface water ❑ ..:Cesspool:or privy Is within 50 feet of a bordering vegetated wetland or aaalt marsh : t5ins•:3/.13. ^:.. Title 5 Official Inspection Form:Subsurface Sewage.Disposal System.Page 3 of 17::.. Commonwealth of Massachusetts W Title 5 Official hsipection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 361 Meghan Road Property Address William O'Neill Owner Owner's Name information is required for every Hyannis p Ma 02601 2-12-18 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.;w. D) System Failure,Criteria'Applicable:to All Systems: q. 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 El ® " due:to an overloaded or clogged SAS or cesspool ,Static liquid-level in the distribution box above outlet invert due to an overloaded 0 0or clogged SAS or cesspool :Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than '/Z day flow t5ins•.3/.13. Title 5 Official Inspection Form:Subsurface Sewage,Disposal System a Page 4 of 17.:.. Commonwealth of Massachusetts W Title 5 Official lnspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 361 Meghan Road Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes.. No, ... ElRequired pumping more than 4 times in the last year NOT due to clogged or 0. obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Z Any portion of cesspool or privy.is within 1.0.0 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. Yp p. privy p PRY. An ortion of:a cess oofor rlv Is within 50 feet of a private water su I 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.mustbe 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 p El 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•3/.13. ..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 361 Meghan Road Property Address William O'Neill - - Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no° as to each of the following: Yes No Pumping information was provided by the owner, occupant, or.Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? ® ❑ Has the.system received normal flows inthe previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system:obtained and examined? (if they were not ® available note as N/A) ❑ ® Was.the.facility.or dwelling inspected for.signs of sewage back up? Z ❑ 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 El. ® 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: F. ® ...❑ Existing information. For example,a plan at the Board of Health. pp ) [ Part Determined in the field (if any f of the failure criteria related to Part C is at issue El ® approximation of distance is unacceptable) 310 CMR 15.302(5)] D. System .Information Residential Flow Conditions: 3: Number of bedrooms (design): )Number of bedrooms(Actual ::. 2 DESIGN flow based on 310 CMR 15:203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/.13. .:Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 6 of 17':.. 7 Commonwealth.&Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments ... .. .. ,M 361 Meghan Road sV Property Address William O'Neill Owner Owner's Name information is Hyannis Ma 02601 2-12-18 required for every y page. Cityrrown State Zip Code Date of Inspection D. .ystem:Information Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on'a separate sewage system?(Include laundry system inspection Yes ® No information in this report.) Laundry.system inspected? ❑ Yes. ® No Seasonal use? - ❑ Yes ® No Water meter readings, if available(last 2 years usage (god)): See:below : Detail: 2016-20,944 gallons 2017 32,164 gallons Sump pump.?: ❑ Yes Z. No Last date of occupancy: Current P Y .. Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 holdin tank resent? ❑ Yes. ❑ No Non-sanitary waste discharged to the Title 5 system? ❑- Yes ,❑ No Water meter readings,.if available: t5ins•:3/.13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System Page 7 of 17:: Commonwealth.&Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p 361 Meghan Road: Property Address William O'Neill - Owner Owner's Name information is Hyannis Ma 02601 2-12-18 required for every page. Cityrrown State Zip Code Date of Inspection D. System nformation (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Owner-date of last pump is.unknown 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, 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 obtainedfrom 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. El (describe); t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments ,M 361 Meghan Road V Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) A Approximate age of all components, date installed (if known)and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well,or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: q feet Material of construction: .. ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years i Is age confirmed b a Certificate of Com Rance? attach a co of certificate ❑ Yes ❑ No 9.. y P� � ( PY ) . I� Dimensions: . 1000gallons 101, Sludge depth: t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage.Disposal System t Page 9 of 17 Commonwealth.& Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments °M 361 Meghan Road Property Address William O'Neill -. Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 page. City/Town State Zip Code Date of Inspection D. System.Information (cont.) Septic Tank(cont.) Distance from top of sludge:to bottom of outlet:tee or baffle 26" Scum thickness -- _. 6" Distance from top of scum to top of outlettee or baffle' . Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was.in:working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this,time and should be pumped every two years for maintenance. Grease Trap(locate on site plan): Depth below grade: Net P 9 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•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 10 of 17 . i j Commonwealth of Massachusetts _ Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments ,M 361 Meghan Road Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 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: NA 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.): copy pumping (required).. py ❑ Ye Attach co of currentcontract Is co attached s ❑ No t5ins•3/.13 title 5 Official Inspection Form:Subsurface Sewage:Disposal System:e Page 11 of 17::.. Commonwealth:of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SVB 361 Meghan Road Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 page. CltylTown State Zip Code Date of Inspection. M System nformation (cont.) Distribution Box(if present must be opened):(locate on.site plan): Depth of liquid level above outlet invert NA Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.)` d. Pump Chamber-(locate on site plan): M Pumps in working order: ❑ Yes El .. Alarms in working order: ❑ Yes ❑ :No* Comments (note condition,of pump chamber, condition of pumps and appurtenances, etc.): NA 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: p. t5ins•3/.13. Title 5 Official Inspection Form:Subsurface Sewage:Disposal System.•.Page 12 of 17: Commonwealth of Massachusetts _ Title 5-Official In pectionForm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 361 Meghan Road s Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 page. City/Town State Zip Code Date of Inspection D. :System Information (cont.) Type:: . (2) 6,X6, leaching pits number: leaching chambers : number: ❑ leaching galleries:. number: ❑ leaching trenches number,length: El leaching fields number, dimensions: overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order;at time of inspection with no sign of hydraulic failure; Pit one was% full when inspected and the second pit was dry with a stain line '/2 up from bottom. Cesspools (cesspool mustbe pumped as part of inspection) (locate on site plan): NA Number and configuration . q —Depth to of liquid to:inlet invert P P Depth of solids layer . Depth of.scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow: ❑:.Yes ❑ No t5ins-:3h1 . Title 5 Official Inspection Form:Subsurface Sewage:Disposal System:!Page 13 of IT'.. Commonwealth:&Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 361 Meghan Road .. Property Address William O'Neill Owner Owner's Name information is required for every H annis Ma 02601 2-12-18 y page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) p. Comments (note condition of soil, signs:of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): NA :Materials of construction: - Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure;level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System.•.Page 14 of 17 :. Commonwealth:&Massachusetts Title 5: Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Meghan Road Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 page. Cityrrown State Zip Code Date of Inspection D. System;Information (cont.) Sketch.Of Sewage Disposal:System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply:enters the building. Check one of the boxes below: hand-sketch in the area below, ❑ drawing attached separately REAR B Al-24':: B1-25 1 A2-42 132-41' A3.54' B3•33' O - 0 O t5ins-3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System:•.Page 15 of 17:... Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments 361 Meghan Road Property Address ... William O'Neill Owner Owner's Name information is required for every y H annis Ma '02601 2-12-18 : Zip Code Date of Inspection page. Clty/Town State P P D. System Information (cont.) Site Exam: ® Check Slope. Surface water :. ® Check cellar ® Shallow wells :. >12 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1986 permit on file Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation). ❑ Accessed USGS database-explain: .. You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Comp leteness:Checklist on next.page. t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewagebisposal System',..Page 16 of 17 ... Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a M s•' 361 Meghan Road .. Property Address William O'Neill Owner Owner's Name information is required for every Hyannis Ma 02601 2-12-18 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System:•.Page 17 of 17.... Town of Barnstable OF 1NE taL Regulatory Services sAxxsrns Thomas F. Geiler, Director MASS. �0� Public Health Division rfD MA'S A 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 SEWAGE VILLAGE �� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY h0-C) LEACHING FACILITY:(type),a (size) v NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER PLO BUILDER OR OWNER C�,tkji lJ Dou`J ,T DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 1 C)LO, ' VARIANCE GRANTED: Yes No ly �i7 1 i } �*� Commonwealth of Massachusetts cc as Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 inspection Form dates! . 6N512000.Inspection forms may not be altered in anyway A. Certification knpor Whenlant t ont bout 1. Pro rty infbrmation: _- P owl .we _only the tab key Property Address to move your Av 3'] assor-do Trot use the return key. / v`s me f Y�� 7j e�/ e J-1 t`l0 _�-- h owr'1r�Address CityMbAnlip cue Date of inspection: v�► d v v Date 2. Inspe r. N e f l pr t e� 'r'1 t 0*I J C i �d '`r Y StateZip Code aNumber t } Certification Statement: .7 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 inspeEtion 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 ofa Title 5(310 CMR 15.000).The system: c M 15"es ❑ Conditionally Passes ❑ Fails I �' _P E ❑,Needs F r E ' ation by the Local Appro Autho 9 r0y Q7 inspector's SW Date The system inspector sha submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection,ff the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shalt 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 addrmm how the system will perform in the future under the same or different conditions of use. t5fnsP.d0c•-1IrAW 4 TWO 5 OHicFai ` Inspection Form:Subsurface Sewage Algx"system- Page 1 of 16 ' Commonwealth of Massachusetts - Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. CertMcatign (cons) PRVqVAddren s� ode Omwrs Name Date of n Inspection Summary:Check A,B,C,D or E I always complete all of Section D A)System Passes: L 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: S vs 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 extiltration 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: Wkisp.doc•1112ON roe 5 OfSdW Its FMW-Subsudaw D4asW System. Page 2 of 1@ . Commonwealth of Massachusetts Title 5 official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Ce>Cti�ication (cons) dress Cr 4 yPi 'e--j HLJ hJ state J o 041P owwnees Name Date of InspeCODn B) System Conditionally Passes(conk): ❑ 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 distnbution 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: 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. 11. System will pass unless Board of Health determines In ac nee with 310 CMR 15.303(1)(b)that the system is not functioning In a manner lt 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 saR marsh t5rnsp doc•11/2004 Title 5 Otfidar!nspediorr Form:Subsurface Sewage Dispose!System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official. Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certificatioprnt.) Addrew /3 o'i'-� n^� ��J Q 7 0 code Owners Name bate of lm n C) Further Evaluation is Required by the Board of Health(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 syste has a septic k nd SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a se 'c tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank an S and the SAS is less than 100 feet but 50 feet or more from a private water supply wel 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. V y� tSnw.doc•11/2004 Tfime 5 Official I nspedion form:Sut>surfaoe Sewage Disposal System. Page 4 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certifica 'on (cunt.plrc= f 0,)- 601 c11 Z�r rx J 11 �2 uJ ��j state J Owrees Nance Datearimpecdon 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 dogged 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 dogged SAS or cesspool Liquid depth In cesspool is less than 6"below invert or available volume is less than%day flow ❑ � Required pumping more than 4 times in the last year NOT due to dogged 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 pion of a cesspool or privy is within 50 feet of a prorate 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 colfform 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 Rpm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 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,therelbre the system fails.The system owner should contact the Board of Health to determine what wit be necessary to correct the failure. t5e"doc.112004 Title 5 Oifdal inspection Form:Subsurface Se wage Dispose System- Page 5 of 16 4 , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntwy Assessments Subsurface Sewage Disposal System Form A. C rti catlp (cunt.) � � sf 0j �oi one" �� v�J �/� � V �Code J d Owner's Name Date of 1 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' Section D. YES NO �. ❑ ❑ system is within 400 feet of a surface drinking water supply ❑ ❑ the syste 's within 200 feet of a tributary to a surface drinking water-supply ❑ ❑ the system is to in a nitrogen sensitive area(interim Wellhead Protection Area—NVPA)or a Zone 11 of a public water supply well If you have answered'yes"to any question in Seal- system is considered a significant threat. or answered yes"in Section D above the large system has The owner or operator of any large system considered a significant threat under Section E or failed u Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner shout tact the appropriate regional office of the Department Mvsp.doc-112004 Title 5 Official Inspection Form:Subsurface Sewage Dlsposai System Page 6 Of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Chec ist T c '91 ProperiyAcld J Cjjn v site A10 -,Av code Owner's Name Date of tnspection T Check if the following have been done.You must Indicate'yes'or"no"as to each of the following: YES NO 1!9- ❑ 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? ❑ pt 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 WA) ❑ 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(3xb)] doc•11/20U4 �- Title 5 Otfldal inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection' Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Syst m In rmation P11--i (ZL �TA4W7 Owner's Name Date of hWebtlon Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 152 m 03(for example:110 gpd x#of bedroos): L Number of current residents: Does residence have a garbage grinder? ❑ Yes P� No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No Laundry system inspected? 0-Yes ❑ No Seasonal use? ❑ Yes No Water meter readings,if available(last 2 years usage(gpd)): —� Sump pump? ❑ Yes No Last date of occupancy: 0 elvPate CommerciaUindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): Gallons per day(Wd) Basis of design tlovl►(seats/persons/sq.R,etc.); Grease trap pint? ❑ 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: Last date of occupancy/use: Date Other(describe): t5kup_d=o 1 MAM We 5 Official Inert►Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form. C. Syst m Information ( ) mec7 RTAftess � i . f Od6C) � 4 J �1'0'-krj �.� sale� y Zip cows owners Flame Dais of kispectfion General information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes k/No If yes,volume pumped: gown 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/Altemative 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 ail components,dPtq installed(if known)and source of information: t C) Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc•I IrM 4 Tie 5 O&W Inspection Fomr_Subsurface. sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official. inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Co Sy tem Information ( ) �R state � � �� y� n�L '4J d-W C04:19 owner's Name Dale of n Building Sewer(bate on site plan): Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC other(explain): Distance from private water supply well or n rime: tit Comments(en condition of joins,venting,evidence kage,etc.): Septic Tank(locate on site plan).- Depth below grade: feet Material of construction: ricrete ❑metal ❑fiberglass ❑polyethylene ❑other(e)plain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Yes ❑ No Dimensions: Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness �!- 2 Distance from top of scum to top of outlet tee or baffle E `/7— Distance from bottom of scum to bottom of outlet tee or baffle O • Wow were dimensions determined? �S t51nsp.doc-1 i/2004 Title 5 Ottidal ImVecfim Form:Submface 5eYvage Disposa System' Page o of u Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System informationC*Pt n .) n u n is e-=J ! O'j Stat40 oZ v U 'P code Owner's Name Date of r Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid ley as related to utiet'nvert,evidence of leakage,etc. 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 p Date Comments(on pu * Ing recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as re to outlet inv a of leakage,etc.): Tight or Holding Tank(tank must be p at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): t5imp.doc-11/Z004 Title 5 OtrIal rnspection Form:Sot=uface Se wage Disposef System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form G. System Information (co } 6 � P C J'O tj smote 6'� v �® Code Owner's Name Date or Inspectidn Tight or Holding Tank(cunt) Dimensions: Capacity: t8 PQ Design Flow: gallons per day Afars present ❑ Yes ❑ No Alarm level: Alamo in working order. ❑ Yes❑ No Date of last pumping: ate Comments(condition of alarm and float switches,etc.): 4 Distribution Box(if present must be opened)(locate on site plan): (� Depth of liquid level above outlet invert Comments(note if box Is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.).- Pump Chamber(locate on site plan): / Pumps in working order. V ❑ Yes ❑ No Alarms in woddng order. ❑ Yes ❑ No mnsp.doc•11/2004 Title 5 019dal insp ection Fan:Subsurface Sewage Dispose System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information Z t. 6 14e �� Propep Address citvrro State Zip Code vkj424','_� 4 C � Owner's Name Date of Ins n 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,a plain why: /> J S1&� Type: leaching pits number. "tl L) (((❑��"` 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.): t5insp`doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 . Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form G. System Information n �� . C7.tY1ir r ,��e� �(}t-J t n•.J� Statej„c f aC U t� �Code Owner's Norma Date of I 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 lay Depth of scum layer ✓ V Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydrau ilure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): d AQ Materials of construction: Dimensions Depth of-solids Comments(note condition of soil,signs of hydraulic lure,level of ponding.condition of vegetation, etc.): Mrmp_doc 11/20Q4 rife 5 Oftat Ins pection Form:Subsurface Sewage pisposal System. Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) 13 G 1 HV-P Pmfl"Address w stare �1 code'ac.) 0 Owners Name Date of Inspection 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_ wh Pe, 9,�L��JYI 33 4= Y OJ_C, ��W �y o (91 /,QA C,�� I t6msp.doc•11/2M True 5 Official l aspect w Form Subsurface sewage Disposal system. iPage M of 16 f '. Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 11136 1 Propertypddress M City/T/owrj C, / State i__ a 0 Zip Code f " t' A1J J Owners Name Date of Ins eclion Site Exam: Slope Surface water Check cellar Shallow wells i Estimated depth to ground water: v + { Please indicate all methods used to determine the high ground water elevation: I ❑ Obtained from system design plans on record 1 O / � If checked, date of design plan reviewed: i pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked yyith local Board of Health-explain: } K Rf I� i ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: I j You must describe how you established the high ground water elevation: i e K (�S � C. f � :-✓esS c I�CA4-171-4;1 CID � ?6 Abtt f i t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN OF BARNSTABLE LOCATION 6mj� is SEWAGE # 36-7 o ro VILLAGE '(a ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. Aff ? -y'I SEPTIC TANK CAPACITY �' d LEACHING FACILITY:(type),'a j000 (size) NO. OF.BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER I�ik) BUILDER OR OWNER CPop,)'8 f,) Dowd DATE PERMIT ISSUED: jb y f DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No -� � .. .1 ''��` � .. .� � f ,{ r� � � � -� � � � � ry.,K� . I �� "� �, � -a �I i � � � �� v�•'� 'Ir :: �� L ASSESSORS MAP NO: .. PARCEL NO.: No.A-.j G0 7 0 Fas....#2.!;!=.......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH I..own..................oF... �e�.n. co1�. ----......................................... App irFatilau for Disposal Works Tonstraur#iuu Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (4) an Individual Sewage Disposal System at: A opt ...�� ......S� ..A �. [t.A xtxLKll -----•--•.......... ........c.�..�..............................................•........................................ ` L ti orLo ............¢ ► 2t i. 5 - Owner iAddress a ........................................4 3 So ..yLa... b�r (ems G �tA Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................._.__..___.Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ........................................ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area._______----___----sq. ft. Seepage Pit No--------------------- Diameter----_--------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water------------------------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_____-___---_____. 9 •---------••..................•------•-•------......---..............•.......--••-•-----........----......................................................... 0 Description of Soil......................................................................................................................................................................... x U W ----••-----•-----------------------•--------•-•••-•••----•---------••••-••--•--------------•---------------•- ------------------------ ------- ------- � U Nature of Repairs or Alte ati�ns—An�wer when applicable ______U°___________________ QOO Le - v s ----- .... Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of iiTli: of the State Sanitary Code— The undersigned further agrees not to place the system in operation.until a Certificate of Compliance has beenaued.Dhe board of health. Signed',•y! rb-. :&(o_..Application Approved BYD�a� ---- Date Application Disapproved for the f ollowing asons:---•--•----•••--•---•---•-•-•••-----------•--••••--•---•--•-----••--------••--•--•-------•--•--••......--...._ --------------------------•----------•---.....-----•---------••---------...----------------•-------.......---....---------------------...---------------------------------------------------------------- Date Permit No........... ................ ..._.� .. Issued.--------------------------------•-- --------------- Date J NoR.:'!v 7.... Fps.. .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - 77s 01) .......... OF.'......�.':::'.,r............................ Appliratiou for Uiiputial 10orkg Tonstrurtiou r1trmit Application is hereby made for a Permit to Construct ( ) or Repair (� ) an Individual Sewage Disposal System at: J! (� 2t�1 lllr�dfiY1 t�6. '; `•] . ,,_IIS Location-Address "` or Lot No. ...1 �1 f... ..r.�rt .....e;l:' :a ri Owner, lAddress 1 s ----- ......... ...... Installer Address V Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_______________________________..____.__.__Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of persons.........._----------------- Showers — Cafeteria pI Other fixtures __________________________________ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—NTo_ ____________________ Width.................... Total Length.................... Total leaching area__-_______________;sq. ft. Seepage Pit No-____-__-_-.-._---_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.___--._-___________--. rz, Test Pit No. 2........_.......minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----......................................................................................................................................................... 0 Description of Soil........................................................................................................................................................................ x V ----------------------------------------•--•--------•------•-------•--•----------••--------...------...-----------------•-------.._...•-----------------.._._._..........................-............. W U Nature of Repairs or Alterations—Answer when applicable. -:_= _ ±______--- '-'' -'-- - -^' `-- ! / = -=------- f•}:-r).Fi lr� l r tl r 1, ,�:+• {a_-- .,�t.t--- -- � (C't Agreement: v The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of i i=-F. E 15 of the State Sanitary Code— The undersigned 'further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.--••1=--..--=••-`--j`'--..--. •�„. .•1,� A - f r ...-•--••-•••................••- Application Approved B - PP PP Y-------------- ----•--• ----._`.....C;.�? _...--•--------'----•------------• Date A Date Application Disapproved for the following easons-........................................................................................................._.- -------------------•------....••-------•--------------•-•-••-.._..-••-•----------------•••••••----------•---........__..._..--•---••---•-•••••••...-•---••---•--•--•-•---••---•-----•••................ Date t b v................ Issued �__----- --- Permit No.......... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrfifirttte of Toutpliuttrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�L) by............ ...........................-..............................----...-----•-------------•--••----------•----------------------------......_._...------•----••---••- Installer at3. - :- K _ 1 -- --•-----•-•------------------•--• ---------------------------•------------- has been installed in accordance with the provisions Of ITm�r' j of The State Sanitary Code as described in the SM.) �ii - �-V----•-----•----- dated------I u Y/--u- --- ------------ � application for Disposal Works Construction Permit Na J_ ___�_._i� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL PUNCTION SATISFACTORY. � t DATE.......... ........................................... Inspector.... 1.................._................................................. THE COMMONWEALTH OF MASSACHUSETTS l BOARD OF HEALTH ..... --------•...........................••._._._......._.. ,, l r le PTO. ...51.._./.J.�u FEE �...__...---•--• �iu�ro ,I�l Turku �o�tuirttr�ion rruti� Permission is hereby granted.... ...G .,;: -------••--------•--------------•-•-----------------•---•----------------------••--•-••-------=----..__....------- to Construct ( ) or Repair ( an Individual Sewn Disposal System atNo.------3 f ?. :t. _G,, ..._....!...._........................ . . ............ ------------------------.----------------------------------------------- Jtreet as shown on the application for Disposal Works Construction Permit Dated_._ y C -------------------------------------- 1, T ) v ' J s of d oL Health DATEE ----•--••---•-•--•---••---•------•••-••--•--•-•--•--••----•-•--•- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS r�