The URL can be used to link to this page

Home My WebLink About0154 LONGVIEW DRIVE - Health 154 Loncyview Drive Hyannis / A= 251 — 076 l P Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,V 154 Longview Drive Property Address t Allison Cloutier Owner Owner's Name information is required for every Centerville ✓ MA 02632 05/04/2021 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 filling out forms A. Inspector Information :Sl4r (696zo on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return key, Company Name _.._._. 52 Rivers End Road ITV Company Address Teaticket Ma. 02536 City/Town t State Zip Code 508-280-3356 S13938 Telephone Number License Number ' F B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 05105/202.1 spector'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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. , F Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-'Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;v 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a leaching trench with stone. At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. i ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c� Commonwealth of Massachusetts a p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Cityrrown . State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form `e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: ti 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 18, e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. � .154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is Centerville MA 02632 05/04/2021 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® 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 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is I required for every Centerville MA 02632 05/04/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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(gpd)): town water Detail: In 2020-71,808 gallons were used and in 2019-50,864 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24„feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information.(cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"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: H-10 1000 gallon 21v Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 34" " Scum thickness Distance from top of scum to top of outlet tee or baffle 511 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge 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 recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle was in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (ori pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ki�vv'; — Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1�P 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No f 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.1 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville _ MA 02632 05/04/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: One-apx 60' ❑ leaching fields number, dimensions: ❑_ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 'cam Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.)• Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): . At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t . t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: , Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 154 Longview Drive ,p. — Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 G b. • j,S/�.�fy C t5insp.doc•rev.M 2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 `cam Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information,(cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 plus feetfeet 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: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Longview Drive Property Address Allison Cloutier Owner Owner's Name information is required for every Centerville MA 02632 05/04/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: , 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included J • t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 P C01IMONN�T ALTH OF MASSACHU SETTS 1: EXECUTIVE OFFICE OF ENVIRONME\TAL AFFAIRS �• -,_� 4. DEPARTMENT OF ENVIRONMENTAL PROTECTION 'cam BONE RI\TER STREET. BOSTOI: i\ZA 0210E i61 i 292-550ti TRUDYCOXE Secretan ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:154 Longview Dr . Name of Owner Shelia Cabral C e t o ry i l l e r MA Address of Owner Date of Inspection: �3.6- E Name of Inspector:(Please Print) . R obinson Sr. I am a DEP approved system)inspector rsuant to Section•15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinsoneptic. Service MalingAddress: PO BOX 0 9. Centerville , MA Telephone Number: 7T7 5_ Fi v CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewwa a disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: 4�1j i Date: The System Inspector shall subrTiit a copy of this inspection report to.the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspectiori.' I'f the systei`n 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 appiopriate;regional office of the Department of Environmental Protection. The original'should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS RIOVET G, OCT 1 5 1999Ik y .. TowNOFBARNSTAje ?Si HEALTH oEPr revised 9/2/98 Page IofII `i ✓—ted on Recycled Paper` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION (continued) 'rop"Address: 154 Longview Dr. , Centervil x e Jwner: Shelia Cabral Date of Inspection: ! _3 p.- 4 g INSPECTION SUMMARY: Check O A C, or D: A. SYS PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. YSTEM 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. Indicate y s, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed 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 the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a.year due to broken or obstructed pipels). The system will pass inspection if(with approval of the Board of Healthl: broken pipe(s) are-replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 154 Longview Dr . Centerville Owner: Shelia Cabral Date of Inspection: C. THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the p blic health, safety and the environment. 1) S STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within-50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well The system has a septic tank and soil absorption.system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 154 Longview Dr. , Centerville owner: Shelia. Cabral Date of Inspection: 9 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this d ermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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 1l2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYS FAILS: You must indicate it "Yes" or "No" to each of the following: The follo ing criteria apply to large systems in addition to the criteria above: The sys em serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health_ d safety and the environment because one or more of the following conditions exist: Yes ' No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the epartment for further information. revised 9/2/98 PagE.-of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO N FORM. PART B CHECKLIST Prop"Address:154 Longview Dr. , Centerville' Owner: Shelia Cabral Date of Inspection: 3 O^9 g Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. V _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System, have been located on the site. _ The septic tank'manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,'dimensions,depth of liquid; depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria.related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)1 The facility owner(and occupants,'if different tram.owner)'were provided with information on the proper r aintenaarik-0f Subsurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Iroperty Address: 154 Longview Dr . , Centerville Owner: Shelia Cabral Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:�g.p.d./bedroom. 7 Number of bedrooms(de ign): Number of bedrooms lactual):J Total DESIGN flow L d Number of current residents:A/A Garbage grinder(yes or no): rg Laundry(separate system) (yes or no):40, If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):,dl—b Water meter readings, if available (last two year's usage (gpd): Sump Pump(yes or no),dZ-6 Last date of occupancy: COM RCIAL/INDUSTRIAL: Type of stablishment: Design fl w: qpd ( Based on 15.203) Basis of esign flow Grease tr p present: (yes or no)_ Industrial aste Holding Tank present: (yes or no)_ Non-sanit ry waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available: 1908 142 , 500 gal. Last dat of occupancy: 199'7 306, 750 gal. OTHER (De cribe) Last d e of occupancy: GENERAL INFORMATION PUMPING RECORDS and so if information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM 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) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and scurce of information:T�s ' Sewage odors detected when arriving at the"site: (yes or no)A 0 revised 9/2/9E Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address:154 Longview Dr. Centerville e Owner:Shelia abral Date of Inspection: BUILD G SEWER: (Locate site plan) Depth bel w grade:_ Material construction:_cast iron_40 PVC other(explain) Distance from private water supply well or suction line Diamet Comm ts: (condition of joints, venting, evidence of leakage,-etc.); SEPTIC TANK:_ (locate on site plan) t Depth below grade: ' Material of construction: ✓concrete_metal_Fiberglass Polyethylene_other(explain) If tank is metal,list age_ (sage confirmed by Certificate of Compliance_ (Yes/No) � L,1SL Dimensions: ' ae Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: :I— � L ' Distance from top of scum to top of outlet tee or baffle:_ y Distance from bottom of scum to bolt outlet tee "r baffler How dimensions were determined. 1` �• ,omments: (recommendation for pumping, condition of inlet and outlet teesor baffles, detth of liquid level in`rrf4 to outlet invert, structural integrity, evidence of leakage, etc.) 1 D O—G, �l�/r Z d y�" /d 1� L !S- 02 GREA E TRAP: (locate n site plan) Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass Polyethylene_other(explain) Dimensi ns: Scum t ckness: Distanc from top of scum to top of outlet tee or baffle: Distanc from bottom'of scum to bottom of outlet tee or baffle Date last pumping: Co ants: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage,etc.) AL revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ►ropeM Address: 154 Longview Dr. , Centerville Owner: Shelia Cabral Date of Inspection: 9—36— Q� TIGHT OR H DING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site an) Depth below grade Material of constru ion:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes_ No_ Date of previous umping: Comments: (condition of i et tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:,y (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal) evidence solids carryover, evidence of leakage into or out of box, etc.) - h iS 6 mil PUMP CHA BER:_ (locate on si a plan) 'n w rkin order: Yes or No Pumps i g ( ) Alarms in w rking order(Yes or No) Comments: (note condi ion of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2/98 PaFc8ofII • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION(continued) 'rop"Address: 154 Longview Dr . , Centerville . owner: Shelia Cabral Date of Inspection: --.36-y SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits; number: leaching chambers,number._ leaching galleries, number:_ �. leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number._ Altemative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CCESS OLS:_ (locate site plan) Number a d configuration: Depth-top of liquid to inlet invert: Depth of s lids layer: lepth of s um layer. + . Dimensions of cesspool: Materials ol construction: Indication o groundwater: in low (cesspool must be pumped as part of inspection) Comments �. � (note con on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY. (locate o site plan) Materials 'I construction: Dimensions: Depth of olids: Comment (note co dition of soil, signs of hydraulic failure, leyel.of ponding, condition of vegetation, etc.) revise-6 9/2/98 Pagc9of11 ~ S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) boperty Address: 154 Longview Dr. , Centerville owner: Shelia. Cabral Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ll\ l � cl �D r O revised 9/2/98 Page 10of11 r ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rop"Address: 154 Longview .Dr .', Centerville Owner: Shelia Cabral Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater�Z� Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record . served Site(Abutting property, observation hole,'basement sump etc-.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you establish d the High Groundwater'Elevation. (Must be completed) d-�� lq g revised 9/2/98 Page 11of-11 TOWN OF BARNSTABLE _ L ,. A' 'iON /b �t��'l� SEWAGE # � '.ILEfIGE `dam ASSESSOR'S MAP &LOT r l l O �1G IN-=TALLER'S NAME&PHONE NO. AAu�d" (� �` SEPTIC TANK CAPACITY /d 6_6 LEACHING FACELI TY: (type) e1-tr °d" - (size) NO.OF BEDROOMS BUILDER OR OWNER C A 41e�,V PERMTTDATE:Z COMPLIANCE DATE: 19 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 �`�- _ � �. c� � H. i� 4 -� `r' V� �. �� , � , �J � � _� �� tY �. S" s u '`, No. Fee 4 0.0 0 tHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACH SETTS Application for Migozar *pztem COri!gtrurtion Permit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Loc Lion Address or Lot No. Owner's Name,Address and Tel.No. � 54 Longview Dr Shiela Cabral Centerville 103 Orange ST Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � W.E. Robinson Septic Sery P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( np 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 Description of Soil sand Natinof R4epairs or Alterations(Answer when applicable) install a Title 5 leachtrench bU x and new d—box Date last inspected: e 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 a d not to place the system in operation until a Certifi- cate of Compliance has been issued by this B o alth.., 2 Signed 1 i Date 3/ — Application Approved by el Application Disapproved for the following reasons Permit No. 2 6 — �Q Date Issued v: No. � _ - _. Fee 4 0.0 0 HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACH SETTS. 01pplicatton for Mtoaat *peum Construction Permit Application is hereby made for a"Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Loc ti ddress or Lot�vo. Owner's Name,Address and Tel.No. � � Longview Dr Shiela Cabral Centerville _. 103 Orange ST . . Installer's-Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinson Septic Sery P.O. Box 1089 - Centerville 776-8776 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( nq 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, Description of Soil sand Nat�gfxloepaiari�Al a ati?l.(Answer when applicable) install a Title 5 leachtrench Ci D f f • 1 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- .Z4 „ cate of Compliance has been issued//b''y--this B o alth., Signed ! / Date 13- Application Approved by Application Disapproved for the following reasons ° Permit No. _ �.�a Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( X)on by W.E. Robinson Septic Sery for Shiela Cabral as 1�°ngv eW Dr Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. S`� dated Use of this system is conditioned on compliance with the provisions set forth below: .� No. �� Fee 40.00 Cabral THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Iigpont *p4tem ton.5truction Permit E Permission is hereby granted to W.E. Robinson Septic Sery to construct( )repair( X)an On-site Sewage System located at 154 Longview Dr Centerville 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. All construction must be completed within two years of the date below. Date: 13 — !6, Approved by . CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 3 9 � , concerning the property located at Z. L e V/2 " meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase inflow and/or change in use proposed • There are no variances requested or needed. R Ati j SIGNED L DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. �� C C�� i \ �. y L �� . � r � � � , k � , AsBuilt Page 1 of 1 � N r� `, 3� L O SEWAGE P RMIT N0. vi— VILLAGE INSTALLER'S �NAME i ADDRESS iUILDER 0 OWNER r��co �L DATE PERMIT ISSUED DATE COMPLIANCE ISSUED http://issgl2/intranet/propdata/prebuilt.aspx?mappar=251076&seq=1 6/23/2011 TOWN OF BARNSTABLE LOCATION S ,iJ .rJ bAt SEWAGE # ?P- 2217 VII,L1r►GE ASSESSOR'S MAP & LOT INSTALLER'S-NAME & PHONE NO. 177 f— 0 yy� SEPTIC TANK CAPACITY 10co . Gs 7- Dis P 8 or LEACHING FACILITY:(type) /000 G LA peg size) /D o 6.41 NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER PwS BUILDER OR OWNER DATE PERMIT ISSUED:TLee DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No �/ W 4A ** g L w` � t � o J xo, FEB THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH ......................OF. r..�.a-LE......................................... Appliration for Disposal Works, Tonstrurtiun Prrutu Application is hereby made for a Permit_ to Construct ( ) or Repair an Individual Sewage Disposal System at: , --- Loca•on-Address` qr Lot No. ..................... ..... a..� _. k+t. . '' R....................................•-•--- ....... ......LawJ Owner Address aA..C.._'k.............................................................................. `�-9........r4VA a . .810ax.....Aj-._.......---............................. M .Installer Address Type of Building ` Size Lot...........................Sq. feet U Dwelling—No. of Bedrooms..........2.............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) • a' Other fixtures ..---....-•••-=--•-•-•-••••••••--- d ----•-..--------------------•-•-•---•----------------------••--------------...._---•--.._.........._... WDesign Flow............::...:...:......................gallons per person per day. Total daily flow............................................gallons. W ;Septic Tank—Liquid capacity............*gallons Length.:.............. Width.,............... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length__t......:......... 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......................................... a Test Pit No. 1................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........................ x ' 0 Description of Soil...................•--•---•---......---...---............------••----......-•---------------•----.....------------------......---------...------------------=-----..--... x w -----------------------------............................................................................................................................... ...-••••.............. Uw Nature of Repairs or Alterations—Answer when applicable__-__t!.�E 4: r..._S._......4_�"pTib..... _.....�OOD••-_6S.r ----------=-----------------•-•-------- --•...._.... •-•--•. ......•• ••-•--......-•------• •---•-•. ••-••-•. ---------•-- Agreement The undersigned agrees to install the aforedescribed Individual.Sewage Disposal System in accordance with the provisions of,i Ili L L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in -operation until a Certificate of Compliance has been-issued,by the board of h alth. r. Signed.-- &AlliC_' •. e,�,. -� ....... ----------- -- Date Application Approved By..........-0 U -�� `�`�"`�`"�� ---- S".D te Application' Disapproved for the.following reasons----------------•--------------------------------------------....---------------•---••-••......•.......:.......- .......-•--•--•--•-.......-•-•--------------•------•-------------•-.............................................-•----•-•--•--••---••••-•---•.................................... ...-•------- Date ,. Permit No........... .................... Issued..................................................... - T, Dau �."'�'_""^'�^-�-,.-.-"'---•-•..n ......�.,..,.-.-w.n��-.rf��-"."-`',�-�_-•J-�'--�i..."."+..�..rry--lwll,.,�...+.:,.r..�...:....,,T+�eti�� .- '-•.,....-..-.4i. ...��-.^..-�...y �ti_. -. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................0F........AA.&. 57-./1J.L ..........._.......................... Appliration for Disposal Works Tonotrurtion 1rrmi# Application is hereby made for a Permit to Construct ( ) or Repair (Le) an Individual Sewage Disposal System at: .....,,�S,�1l?.��f�7i: _ �....... . ......��•• Vt/ [7I � ------...•............................ ............................................... Location-Address orN ..............�.1..�.G!.!.�..:.:..�.:...:.�.�...'g... .................... ......./: .�...... Ob....... One Address .. ....--•-- e----------------•------------------------- ......9.........rn�� .. _....�---•--•--•-•-----------•••.... ..... ll... Instar Address ' . Type of Building Size Lot............................Sq. feet �.. 'Dwelling—No. of Bedrooms..........-��.............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building a YP g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_--___-_--__-. Depth................ x _ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 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........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M ---- •---------------------------- ---........ -........... •-------•-•-----------..-•-•--------------- --------------------------------- --------------------•--- 0 Description of Soil........................................................................................................................................................................ •----••----•-•-------------••----••-••••---•--••••--•--•••-•-••••-•--••••-• ---••••-•••-----••••••------•-•--•-•••--••--------•---••---••--••••••••--•••••------------•-------...........-----•--•-.... U Nature of Repairs or Alterations—Answer when applicable-_____�!±4........l......__ .....-...... •• --•--.•. •-••.•-• --•---•. ........• -••••--•......-••-....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...... =1 ------ -------- ................... ---- � Date Application Approved BY - ..._ ._ �l ve-a�a.a �t............ '� �"', r.-�.ly.-.iEr' Date Application Disapproved for the following reasons--------------------------------------------------------------------------------------------------------------- ....................•--••-•-•---------•------------...------....----------------------...----...-•-•----•-•-•--•------•----•---------•...•••---•--•••-••----••--••-•---....•---•••••---•••...••-------•- Date PermitNo...........� -------------------- Issued_....................................................._ Date ---------•--------- ,-------------- —————— THE COMMONWEALTH OF MASSACHUS.ETTS BOARD OF HEAL/T�jH� i. ...........f..... ............OF......... .. ....... lt'T�.................................... Trrtifiratr of Tontplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired PC) bYN4. °-, ---- ------------•............................................................................ .... Installer at ... L' cu' 0.--�'----•--...-----1 't .... c............................................................ has been installed in accordance xfAth the provisions of TIT T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.___... �:._ ;-7....... dated................................................ THE ISSUANCE OFT IS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIOI1SATI FACTORY. a tS DATE ` �.�! Inspector...y. ..............1�!..!/�....------.........--- f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 ............ C iht ....,OF..........�/: e*r No.••- .... ..... FEE..... ............... Disposal Works Tonotrudion rrmit Permissionis hereby granted........... ...C'. �-------------.-----------•--------------•--------------------------•--------------........-•------.......... to Construct ( ) or Repair ("X an Individual Sewage Disposal System at No........... I.--/....... L e�.ieee.rtt''.: sty Strcet as shown on the application for Disposal Works Construction Permit NoXQ:o.%.-;.?.. Dated.......................................... •---------------------------- ---------- ............................................. Board of Health DATE.................. ---"-- ` C7 .....-----------------...----