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Home My WebLink About0678 OLD STRAWBERRY HILL ROAD - Health 678 OLD STRAWBERRY HILL,HYANNIS A=273 207 4 TOWN OF BARNSTABLE c LOCATION 03 D ICJ 51raw ba-rrtv d t I SEWAGE # VILLAGE 44e ASSESSOR'S MAP &LOTol Z ' ,07 f INSTALLER'S NAME&.PHONE NO. W F Ap61 nwn �gQf j*C- 77S-F7-7 6 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS J BUILDER OR OWNER W_AS 21 es K t,, PERMTr DATE: —C< _COMPLIANCE DATE: 9 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 3 6F ® O . o� J Commonwealth of Massachusetts � v��J 2 f7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO a Owner Owner's Name f � information is MAN-- MA 02601 7-1-15 required for every page. City/Town State Zip Code Date of Inspection c. 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: A. General Information When filling out forms p the DPI computer,use 1. Inspector: SIT only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 - S14297 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 Sectiog 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-1-15 Inspe�cto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. , ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �0OSysem �S t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal •Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every 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: ® 1 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 MET OR EXCEEDED ALL PASSING REQUIREMENTS AT TIME OF INSPECTION. FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): f r t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR ' 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: . 5• Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert.or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground-water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy ofth'e analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone Il 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G1M , 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owners Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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? ® E 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)] r D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK D- BOX AND 3 MAXIMIZERS Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail HOUSE VACANT FOR SOME TIME MIN IMUM USAGE PER HYANNIS WATER Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design.flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is MA 02601 7-1-15 required for HYANNIS � every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool. ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑' Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-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 'y 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 LEACHING PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: - El cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No' Dimensions: 1000 GALLON Sludge depth: LIGHT t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 678 OLD STRAWBERRY HILL RD Property Address NUCC10 Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityffown 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 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? SCOUR POLE 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 RECENTLY PUMPED ACCORDING TO OWNER Grease Traplocate on siteplan): ( i Depth below grade: feet Material of construction: ❑ concrete „ ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): r 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site,plan): Depth below•grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑, Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE OR SOLID CARRY OVER Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order,'system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: r NO OBSERVATION PORTS FOUND WE DID EXCAVATE DOWN INTO THE STONE SURROUNDING THE MAXMIZERS AND FOUND CLEAN PEA GRAVEL AND 1 1/2 INCH STONE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 MAXIMIZERS ❑ 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.): WE EXCAVATED INTO THE STONE SURROUNDING THE MAXIMIZERS AND FOUND CLEAN STONE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCC10 Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityrrown State - Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is . HYANNIS MA 02601 7-1-15 required for every 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 t5ins•3113 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 Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owners Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain:. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you.established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 678 OLD STRAWBERRY HILL RD Property Address NUCCIO Owner Owner's Name information is required for HYANNIS MA 02601 7-1-15 every page. Cityrrown 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 J Assessing As-Built Cards A)ut.Ge° 3 Page 1 of 2 TOWN OF BARNSTABLE E.� LOCATION b?8 Old57rtawb��N•l 1 SEWAGE �8y VIUAGE A&MC ;W A--d ^a' ASSESSOR'S MAP&LOT 3. t7 INSTALLER'S NAME&PHONF.NO.fin(f AD6 i 0=n t0 c. 77$'V SEPTIC TANK CAPACrrY I/0 00 � LEACHING FACILITY:(type) .3/19Ak/m/Ze rg (size) a F4- NO.OF BEDROOMS 3 I;IJII.DER OR OWNER PERMrTDATE ,�L-'�� COMPLIANCE DATE... r1 ^9k 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 Weiland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i I I ) at, O. x � i � x�r http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=273207&seq=l 7/8/2015 4 S .., 15b 'dSy w. } - F{ t ,f` i .r No. Fee $5 0 . 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ye. ZIpprication for OigaaY *pgtem Construction Permit Application for a Permit to Construct( )Repair 1rx)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 678 Old Strawberry Owner's Name,Address and Tel.No. 7 9 0-2 81 6 _ Assessor'sMap/Parcel Hill Rd, Centerville Jerold Wa'seleski 678 Old Strawberry Hill Rd, Centerville Installer's Name,Address,and Tel.No. 7 7 5-8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service PO Box 1089 , Cneterville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. 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 Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 L e a c h i n f consisting of D-Box and three stone packed maximizers . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo d of Health Signed Date '- Application Approved by Date Application Disapproved for the f wing reaso s Permit No.. — Date Issued - - ------ -_- - - - - - - - - - - d #is `No. r __- Fee $5 0.0 0 w' - Y e r t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i` Yes PUBLIC HEALTHY DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS ZippYication for 0igpogal*pgtem Congtruction Permit Application fora Permit to Construct( )Repair�CX)Upgrade( )Abandon( ) El Complete System 11 Individual Components Location Address or Lot No. 678 Old Strawberry, Owner's Name,Address and Tel.No. 7 9 0—2 81 6 Assessor'sMap/Parcel Hill Rd, Centerville Jerold Waelleski 678 Old Strawberry Hill Rd, Centerville Installer's Name,Address,and Tel.No. 7 7 5—6 7 7 6 Designer's N e,Address and Tel.No. A'•- W E Robinson Septic Service - F PO Box 1089, Cneterville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.,ft. Garbage Grinder( np Other Type of Building N '@�Pess Tqs Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ' p Type of S.A.S. a� Description of Soil X sand y Nature of Repairs or Alterations(Answer wheplicable) Title 5 Leachinf consisting of D-Box and three stonepabked maximizers. 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 Certift= cate of Compliance has been issued by th' Bo dof Health Signed ' Date Application Approved by ' , Date Application Disapproved for the f wing reasons J ` Permit No. —' '�!+� ,. # Date Issued 4-71 ,.._-�T-H;COMMONWEALTH OF MASSACHUSETTS r 4. Waseles6 j1c " �LE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (Xx)Upgraded( ) Abandoned( )by at 678 Old Strawberry Hill Rd Centerville onstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer W F Robinson Septic Service Designer The issuance of this permit shall not be con d as a guarantee that the system ill function as designed. Date - �— Inspector ------ l No. Fee $5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Waseleski iOoaf *pgtem Con.5tructfon Permit Permission is hereby granted to Construct( )Repair( X�Upgrade( )Abandon( ) System located at 678 Old Strawberry Hill Rd Centerville, MA 02632 Installer: W E Robinson Septic Serit*ee and as described in the above Application for Disposal System Construction Permit.The applicant recognizes hi er duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction rat st be oomp ed within three years of the date of t pe it. ' Date: Approved by i NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systeuts-O lty. CERTIFICATION OY SKETCH-AND-APP-L--ICAT-ION-FOR-A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENOINEERED-gIANS)- I, - William F_Rnhimsnm,,Sr. . .,hereby,certify-that-the-application-for disposal-wr rks construction permit signed by me dated �' - _ , concerning the property:loeateci at--- 67&0_l Stra:wherM HWL"F fen lea meets alkof the following criteria: * There-are-no-wetlands-within-fWfeetof-the-proposed-leaching-facility. * There are no private wells within 150 feet.of the.proposed septic system. * There-is-no-increase-in-flow-andforchange-in-use-proposed. * There are no variances requested or needed. * lf-the-proposed-leaching-facility will-be-located-with-250-feet-of-any-wetlands;the bottom-of-the- proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater-table-elevation. Please complete the following: A)-Top-of-Ground Elevation-(according to-the-Engineering-Division G.L-S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED DATE LICENSED SEPTIC SYSTEM INSTALLER-IN THE.TOWN-OF BARNSTABLE NUMBER -204998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan-should-be-submitted): 1'S oa TOWN OF BARNSTABLE LOCATION 678 D� S-fRa,wbQ/r� 1�' I SEWAGE# VIILAGE Cil' rYf ASSESSOR'S MAP &LOT 3 07 IN 'TAL LER'S NAME&PHONE N0. W F RDE� nSA�I 5e p f i c" 772 p7 6 SEPTIC.TANK CAPACITY 1, 000 LEACHING FACILITY: (type) 3 rI7Ak/m/Z (size) �'� NO;OF'BEDROOMS BUILDER OR OWNER L��AS Ies K P.ERMIT DATE: �'i^L q1� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private;Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 2W feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Jr x�r fib F a Soo � � Commonwealth of Massachusetts Executive of Environmental Affairs El . � Department of Environmental Protection J U L 1 19n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A '•�a CERTIFICATION C� 9 Ile Property Address: 2A Old Strawberry Hill Rd.-Ge�lc, Ma. Address of Owner: James Fabrizio (if different) 74 H arbor R oad. N orwell, M a 02061 Date of Inspection: 06/20/96 Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system �`- Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s Signature: Date: 06/22/96 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (90) 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 278 O Id S trawberry H ill R oad. Centerville, M a. O wners : James Fabrizio Date of Inspection : 06120/96 INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: - I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate (Y,N, or N D). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, 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 conforming septic tank as approved by the Board of H ealth. --- 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 H ealth). ----- 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 pipe(s). The system will pass inspection if (with approval of the Board of Health): ----- broken pipe(s) are replaced ----- obstruction is removed SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 279 O Id S trawberry H ill R oad. Centerville, M a. Owner : James Fabrizio. Date of Inspection : 06/20/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 278 O Id S trawberry H ill R oad. Centerville, M a Owner: James Fabrizio Date of Inspection : 06/20/96 D) SYS T E M FAI LS (continued) -- 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 over- loaded or clogged SAS or cesspool --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 'cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 278 Old Strawberry Hill Road. Centerville, Ma. Owner: James Fabrizio Date of Inspection : 06/20/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- the system is within 400 feet of a surface drinking water supply --- the system is within 200 feet of a tributary to a surface drinking water supply --- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. I S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 278 O Id S trawberry H ill R oad. Centerville,M a. Owner: James Fabrizio. Date of Inspection: 06/20/96 Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components, excluding the Soil Absorption System, have.been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions,depth of liquid, depth of sludge,depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper mair)tenance of Subsurface Disposal System. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 278 Old Strawberry Hill Road. Centerville, Ma. Owner: James Fabrizio Date of Inspection: 06/20/96 RESIDENTIAL: Design flow : 5�c gallons Number of bedrooms p Number of current residents: 0 Garbage grinder (yes or no) : t3 Laundry connected to system(yes or no): Seasonal use(yes or no) : P:, Water meter readings, if available: r,) Last date of occupancy : 5 COMMERCIAL/INDUSTRIAL : Type of establishment: Design flow : gallons/day Grease trap present: (yes or no) Industrial waste holding tank present (yes or no) : Non-sanitary waste discharged to the Title 5 system [yes or no) : Water meter readings, if available : Last date of occupancy : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information : N)\;9'% - ."-e' v.. ?n:4��.�'`�1........... j System pumped as part of inspection(yes or no):....!. ......... if yes, volume pomped: .................... gallons Reasonfor pumping ............................................................................................................. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 278 O Id S trawberry H ill R oad. Centerville, M a. Owner: James Fabrizio. Date of inspection: 06120/96 TYPE OF SYSTEM Septic tank/distribution box/soil absorption system --- Single cesspool --- Overflow cesspool --- Privy --- Shared system Eyes or no) (if yes, attach previous inspection records, if any) --- Other (explain)........................................................................................... APPROXIMATE AGE of all components, date installed (if known) and source of information •C.�4�t.:::`ri?S........r.�.i:..............................:.................................................................................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no)....1 ? SEPTIC TANK : .°:?.`:.` ..... (locate on site plane Depth below grade: . �.`.... Material of construction: .. S_. concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ `j C4 Y Dimensions: Sludge depth:....a ....... Distance from top of sludge to bottom of outlet tee or baffle:.....3.? .................... Scum thickness :.....5............. Distance from top of scum to top of outlet tee or baffle: ...........1.C).`.'...................... D istance from bottom of scum to bottom of outlet tee or baffle:..!\................... Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invent,structural integrity, evidence of leakage, etc.)...................... ` .. .... .. �:-.7::.:-.. •...... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 278'01d Strawberry Hill Road. Centerville,Ma. Owner: James Fabrizio. Date of inspection: 06/20/96 GREASE TRAP : ..... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................ ...........................................................................................:.................................................... ................................................................................................................................................ TIGHT OR HOLDING TANKS:.....U.) (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 276'0Id S trawberry H ill R oad. Centerville M a. Owner: James Fabrizio Date of inspection: 06/20/96 DISTRIBUTION BOX:..!��5 (locate on site plan) Depth of liquid level above outlet invert:... {.�?c�.D...wl Comment: (note if level and distribution equal evidence of solids carryover, evidence of leakage into or out of box, etc.).�Z?- Q-..�. �. a�� ...:.�:�6a:�� .�,�r .. ::;:ate.....uC ..` ��, ............................ ................................................................................................................................................ PUMP CHAMBER:....`•()... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOILABSORPTION SYSTEM (SAS):.... <:s........ (locate on site plan, if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ ................................................................................................................................................ Type: leaching pits, number: ..I�..l�Xc�,t leaching chambers,number:........ leaching galleries, number:........... leaching trenches,number ,length:..................... leaching fields, number, dimensions:................... overflow cesspool,number:.......... Comments: (note condition of soil ,signs of hydraulic failure, level of ponding, condition of vegetation a0 /4' 1 C -_ cs �� II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 278 Old Strawberry Hill Road. Centerville, Ma. Owner: James Fabrizio Date of inspection: 06/20/96 CESSPOOLS:.....N.Q... (locate on site plan) Number and configuration: .............. ....... ........ onfiguration: .............. ....... ........ Depth-top of liquid to inlet invert: ........................... Depth of solids layer: ............................................... Depth of scum layer: ......................................... Dimensions of cesspool: ...................... Materials of construction: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................ ................................................................................................................................................ PR IVY : ...N...0..... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . ................................................................................................................................................ ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 278 O Id S trawberry H ill R oad. Centerville, M a. Owner: James Fabrizio. Date of inspection: 06/20/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' L � Z Pt 2 L 2Vo f-'Z' `i DEPTH TO GROUNDWATER: Depth to groundwater: ....3D.feet Method of determination or approximative: rR , ..........................jvC�l +G. h�...CG � a.cr........�a .... { ...... ...AC..c;� c>r-c c ..b.: > �: .,.....! ..:......3`..... ..� ................................................................................................................................................ COMMONWEALTH OF MASSACHUSETTS 44 V L i _ 1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR DEPARTMENT OF ENVIRONMENTAL PROTfEC14N 0\E WINTER STREET. BOSTON. %tA 02108 617.292.::pp OCT WILLIAM F.WELD l 1 Governorp�Bq j9v0 TRt:DY C.- ARGEO P.4UL CELLC'CCI (ly19FpsT99 8 Sc :: Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r !� D'� 1 S. _ PART A ommiss: CERTIFICATION, _ � Property Address: I 7 & D 18 S+ 4")62f/Ly /ZL- Cz�r5 of Owner: T7 V D Date of Inspection: 9�.,�.��Q� J �J (if different) Cct U Ea(,(,?�C,(�/ Name of Inspector: (� I I am a DEP approve system insp or pursuant to Section 13.340 of Title 5 (310'CMR 15.0?lr -` 66J�—�- Company Name: C p ,S Mailing Address: C7 Telephone Number: I_0 R001 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: la � The System Inspector shall submi copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owne- and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure.criteria as defined in 310 CMR 15.303. Any fa re criteria not evaluated are indicated below. COMMENTS: t !>r+�/'C.�Facer Gc: 9 TC e] 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) Pays 1 of 10 DEP on the Wortd Vft Web: Attp:/Avww.magnetstate.=.us/dep 40 Printed on Recycled Paper f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES continued) 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 Board of Health). Describe observations: 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION 15 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 protec public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT F WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: FUNCTIONING IN A MANNE. _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES T 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 to a surface water suppy l 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 the well.is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal tc less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: Dl SYSTEM FAILS: You must indicate er.-.er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basic for this determination is identified below. The Board of Health should be contacted to determine what will be necessary the failure. to come 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 1/2 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 SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 3.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following: Yes Nh 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 hafeen receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently as part of this inspection. _ As built plans have been obtained and examined. Note 4 they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ 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 lees, 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:I5-64r'-1-7- /74,14"I The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance Sub-Surface Disposal System. _ Existing information. Ex. 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) [15.302(3)(b)) (revised 04/23/97) Peg* 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: f/ D .p.cldbedroom for S.A.S. Number of bedrooms:3 Number of current residents: D Garbage grinder (yes or no): stvO 11// Laundry connected to system (yes or no):r�s Seasonal use (yes or no):j�W.L'4,(.V4r,,v cj le-e Water meter readings, if available (last two (2)year usage (gpd): �/11 Sump Pump (yes or no):ay0 Last date of occupancy: UWK wowti -�v�C ccras.,��s COMMERCIAUINDUST t R AL. Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: PE 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: /JL�ayLs rL rl A-'CD e—'4L/-ri x. GZL -7-7 Sewage odors detected when arriving at the site: (yes or no)jd26 (rwinad 04/23/97) )a" 5 of 10 ' " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: YZ_ 5 (locate on site plan) Depth below grade: Material of construction: concrete_metal _Fiberglass _Polyethylene—other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions:- ,k QX� Sludge depth: 6 is Distance from top of sludge to bottom of outlet tee or baffle: P�2Ort' �e 1 Scum thickness:// Distance from top of scum to top of outlet tee or baffle: G Distance from bottom of scum to bottom of outlet tee or baffle: T How dimensions were determined;paeA rater..« T,vl�" t' 1 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, dep!MfI Wd I vel in relation to outlet invert, structural integrity, evidence of leakage, etc.) r � _ —s.rTgac .t SdeJ / �0 c y-.Tn Cwc � LFis�s4L� GREASE TRAP:±�/AA (locate on site plan) Depth below grade: Material of construction: _concrete_metal_Fiberglass _Polyethylene—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revis*d 04/25/97) )age.i of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:,(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes;_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: S (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) C LE "c A20 2/L T `2 PUMP CHAMBER: ZA (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) I (revised 04/23/97) fape 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):Ye—S 'I —ovate on site pl an,an, it possible; excavation not required, but may be approximated by non intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: /Y[,gy.T�=.TZ�2S Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r-J Iro w nV L U L L CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Depth of solids:_ Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (rwla*d 04/23/97) page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 76 LID � Q TA OSa-� Mgt' (revised 04/25/97) Page 9 of 10 r • e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater Feet ��✓�� /a&&10'CZ) 477'-i9Gh14!5'C) Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) (revised 04/25/97) Page 10 of 10 s L�0 C ALIGN SEWAGE PERMIT NQ. �# DG-IJ 5rn1j4v,dszj -VILLAGE 44 INSTALLER'S NAME A ADDRESS C/F ]'o&l/L_o ,f3i't 0S e 1_3 6 r t U I L D E R OR WNER DATE PERMIT ISSUED '-�� 0� DAT E COMPLIANCE ISSUED �� . =p �� =�, �� ry�%�a_ � d O � � J 1 .. 1,� C ? �' `YM �� el A ' '�/ No....�.. ....L...ZJ Fss.... a.. .......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH uW"+'.?...........OF...... r'n. ....................................... ................................. Apli iration for Diipusa1 Workii Tonstrurtion ramit Application is hereby made for a Permit to Construct ( -4�oor Repair ( ) an Individual Sewage Disposal System at: .................. ... � ....�...r- - .... .................................. �--------`�----------•-----................--------- �• .cation-A dress or Lot No. ! •......�. . ...�----•---------•-••. -•...... ................................... w` c Owner Adress ------. ... •••?. Ac ... Installer Address Type of Building 3 Size Lot-� .` ._`_�........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (NP Garbage Grinder '4 Other—Type of Building No. of persons_________________•__________ Showers — Cafeteria Q' Other fixtures ............................ . Design Flow................ --------gallons per person per day. Total daily flow------ ._ ...................gallons. �b00 Septic Tank—Liquid capacity..........._gallons Length................ Width................ Diameter................ Depth................ ' W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No..................... Diameter.................... Depth below inlet..... ___________ Total leaching a ea.........._.._....sq. ft. Z Other Distribution box ( ) Dosing.tank (k_ 3 al-AltX '-' Percolation Test Results Performed by-_ = a -----••--• Date---�--a.- cA-------.R'..--..---- Test Pit No. 1................minutes per inch Depth of Test Pit................... Depth to ground water_-______________-- (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil......_•- --_ems ......_ G � V -`-- ----- ---- ------..-•-------- ---•••-••••-.. 1..................��----$................G.� 4 ............. . -- - - ....------ ....... - ----------- W ...............- ----------------- - ---------- -- ----------- �� `� U Nature of Repairs or Alterations—Answer when applicable.............................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 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 healllh. 0011owing ed-- l.h....•..."" --- ....Application Approved By---•...... ---••- .........•-•..................•••. -- Date Application Disapproved for the reasons-----------------------------------------•---------------...------------------......-------------•••---••-•••--- ------------ •----------------------------------------------------------------- •----------------- _--•-•----•------.----------------------------------------------------------------------------- Date PermitNo......................................................._ Issued.......................................................^ ^ " ---•------•-----•---- •- ---- Daze Zi .�; { THE COMMONWEALTH OF MA8FsACHU;SETT$ ,4 P't r r .4 BOARD OF HEALTH f ' OF... .. ............ ........ ... ......... .................................... Appliration for jBiapasal darks Tonotrurtion rrmft Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal a System,at: � 6 Lug• .............. S tr• .A {.4.... ..}.. ... �f1.^.,�..... ��.w.\_....... L jq No............ ... ' 4 Q� .......... - .............\ ...............` .. ......................^�_.................................dr ..-... 6wr n �)....................................................;..__ -••-•-- g� Installer y,� c Ad ess Type of liuildi g c `� ize of Sq. feet .... ...... U Dwelling—No: of Bedrooms.._._..... . .............................Expansion Attic ( ) oZ a a Grinder ( ) .� . No. of ersons__________________N_Q Showers — erff (0 ) Other—Type of Building _____________�.._.... _ p ( ) Cafet w Ti Other fixtures ...................•-----............................................... ......................... ... gallons. W Design Flow..................:.........................gallons per person per day. Total daily flow_...._._.___.._.._..__...; sSeptic Tank—Liqu)d\coacity........._._gallons Length................ Width................ Diarite�. ...__. Depth ............ l Disposal Trench—No. ........ `'`R. Width .................. Total Length.................... Total leaching area .sq. ft. Seepage Pit No..................... Diameter.._...__..:......... Depth below inlet..........,....._... Total leaching area. ..,..:. .......sq. ft. E z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..............j,_;O.C41AI X..... .. ,-a Test Pit No. 1..- minutes per inc , TestPir Depth to grohna wiftr f f=, Test Pit No. 2................minutes per inch Depth of Test Pit......... ......... Depth to ground water..._:: . ......-•---•-•-•-•............................................•._....................-----.................................... ................. QDescription of Soil........ ............. ........,.........................--_..... ............_................ ...... w .....-•-•--•----•................ .-r., C..........----- _ 5 ?.-......,..._�'. 'L /�!.�.?,.�...__..__..; .s: .�_. : U Nature of Repairs o Alte#a aiCs —ArC&uw wchenplicableG i'r ;e, ,t � ------,_.. .. _ _.�a a�.:; ......::....... a= Agreement: . . . - .......:. .._ � .....: The undersigned agrees to install.the,aforedescribed Individual Sewage Disposal''Systorn ip r rice with . the provisions of TITLE; 5 of.the State"unitary Code-- The undersigned further,agre®s not to ,l� lle stem in x j operation until a'Certifica#e Coan Zliatice had been issued by t$te board of health -K�` C� } � § �1 ........... ...... fi,.. .5 r •a'{¢*� `e`tYF� _ .r'YV'-t�, ,5 Application Approve. By..,.,.rr:'..... . _ .. ... Y' t, c. tr °` Application Disapproved for he o ozvang reasons:..................... `.. ,.... ..:...........>............. . •. . ..... .� ..........» Permit Nory.................... . .. ....... .Issued.............................. ...f,;:..:... ... Date ek�1�4 D t THE COMMONWEALTH OF MASSACHUSIETTS ,. BOARD OF HEALTH w rr firtttr r�---- i� THIS IS TO CERTIFY, That the Individual-Sewage Disposal Systern constructed or Repaired ( ) by................\ ............. at.................. _." �..:-........................................... ,.-,Installer .......... .,_............. t.�. .-- has been in�Ltfl.& ' ordan withal Io»s of �'' r amta e s es t41M l.l-� �+` oft Cl Sr ;:,, I - q .. applicatioti for Disl>osal Works Construction Permit No . ... ..._ ------ ._.. �dated..- .......... ............ THE ISSUANCE OF THIS CERTIFICATE SHALL OI'44ONSTRUE6 A EE THAT THE '. SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................................... ......._. Inspector................. .. ...............:..... , .. .................... . THE COMMONWEALT.6i OF MASSAC.HUSETTS BOARD OF HEALTH No......................... ..,... ...,.. ® FEE. .. .......... � f` lay Permission is hereby granted.......... ......... ... ........, ..................,.. ...,.................... to Construct ( ) or Repair ! t an Individual Sewage ) s System � t . atNo........ .............................. ..........V �`l �-�.- . .. .., .. a Street /as show, . on theapplicati for Dis al. VVor ' Constre; ' tf . r ' ..rl�i NO,., ... Dat Eie ... .......... ....P 4' DATE-. .-, �:. �® FORM 1255 HOBBS £y WARREN !NC.. PUBLISHERS f f ` r 1 .a 1 S►►.IGLC FAM►L`! - -"�S BEORooM -- -- , Nin C�AtzBAG6 v 'i F h ow z I10A 3 = 330G.Pp ............. _ ArLY ISEPTIC, -rA?,JK = a956•P 0 u5c- I000 GAL. ,LC- D15Po6AL PIT v5E I000 GAL. Zoj /G9 BOTTOM AREA= ., �0 5•F, ,. �j0 S.F.• X. I. O -ToTA1— 1DESIr;N = q25 G.PD• N 97.4 it , � I 'TOTAL DAI►-Y FL-CV 3306.Po y ' � PE2coLAT►oN RATE j 1''IN 2MIN o�L�55 •gyp ,��H ;97•� � i� 97-5 vA of c, RICHARD ti�„•;• t� �Cti !��!/-Y - �' 'I A. ,'. O ALAN DAXTER N!',.: W. r �Nu.2 048Q x v JONES '' �y• �� i N 25100ST • i TOP FWD=1oo.o HOL o�o�Y'4M.QSSo�LG to INV. I �a8�✓C._.. P15T. INJ. �6ptIG �•F3 Z. ,oQA INY e�x y�.G TAr!K cL�sl,►! Gc,►.. 9l� C4l�,G� LP Tu qINV., INY. WASNGD sa,�y "' I -- �GERT1F1Gp PLO P1. A-w i /z. . PRoFILIr �•� NO. 564.LE SCALE ��-=�d �ATrc Gl/3093 I t E.R•r i t~Y THAT T N tc "%u,VVATim,S/rj�1O W N SOW GOMPL`(5 WITNTHG 51o6LIN� ,L�-T- `? Aug SET�,GK 26Q�►2EMENY� oF -CI-1� f 0 w N o I'I3,¢Aa V-5'T•vZ-3L rr A W D 1 S IV:0 T ' LOCPITE0 •WIT141Q T I .E G .000 PL IN D A-T E G /3 ` BAxTEcz.e WYE: INC. • REG I s"c�e�v'►.AN D 5 u>zv�Y�eS Tu15...PL.o.ti 15 WOrT t3n51ro oa AN osTE2VILLE • ems. + ij I>JSTR-uM6NT ;U2ve\( �--rNE oFr= ,F-r5 SuOu� No-T DE 'u5EDTo DETE.FL1^INE L_oT I.INE�j QPPLICA►�'r• f/1�F�/� S/�/T/� 82- - L0,C Ai ION SEWAGE PERMIT - NO. VILLAGE y I N S T A & ER'S NAME 6 ADDRESS r , �As 6UILDE >R OR 6WIllER e DATE PERMIT ISSUED v DAT E COMPLIANCE ISSUED I _ _ _ � . �1( Qv 1 U� �� c - _ , Q ;�. � . .� �� 1 o f. r i i ,,� ' I THE COMMONWEALTH OF.MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal system 11 ------------- C . 5 tc C( A.... ........ .. .A..-. .... ........ ....... ............... ............ ............. Installer Address Z Other Distribution C-ox, ( ) Dosing tank ( ) The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL 1 5 of the State Sanitary Cod The upArsi e urther agrees not to place the system in a of operation until a Certificate of Compliance has ee iss by t o r( al la ------------ Date Application Disapproved for the following reason :.. ....r........................................................................................................ ' ^ ............................................. Date Permit it Date Na✓ 5 ..� ,1 F;ms.... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...........................................................---------------.............. Appliration for Disposal Works Tonotrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair. (.. ) an Individual Sewage Disposal Systemn " C oc I - ds ss Q> ( tor Lot 111� (1/ r .. . .._. ...... . --- - ....... j 4 O r Address --------- ..... :� ..........:..... .............................. Installer Address Type of Building .- Size Lot............................Sq. feet Dwelling—No. of Bedrooms...._ ....._....._ ..___._._Expansion Attic ( Garbage Grinder """ `4 Other--Type .of Building.... r :_..._.___ No. of persons............................ Showers ( ) — Cafeteria ( ) a Q' Other figures d b allons per person per day. Total daily flow................... ..._gallons. W Design Flow _.: .,' P P P Y Y WSeptic Tank--'-Liquid capacrtyl e""gallons. Length................ Width .............. Diameter__.___ . .....Depth................ x Disposal Trench p b ......_.. Width.__ "..... Total Length ..__?.......,Total leaching area....................sq. ft. Seepage Pit-Na : .................. Diameter t0'"�.�. Depth below inlet....--��••- Total leaching area._ 4'.7 Q.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation'Test Results Performed by.......................................................................... Date........................................ 'Test Pit No. 1................minutes per_inch Depth of Test Pit.................... Depth to ground water-____-_______-_------_-- (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' •-................:..................................................................................................:....................................... 0 Description of Soil.................................................... ------------------------------- UNature of Repairs or Alterations—Answer when applicable._--___........:.................................................: ----------------------------•-------•--.......----•---------------•- .......................................................--------------------------------------------------............---.••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Cod The u•nd rsi r urth r agrees not to place the system in operation until a Certificate of Compliance has b e iss d by t ` oar ofea C Z. • i Dat Application Approved By........ �� . R ------------- Date Application Disapproved for the following reasons__ _________________ '. --•-•-•-----------------•---•- -------------- ........--•----------------------•--•--------------------------------------------._..........------------....----------- Date PermitNo.......................................................... Issued-........................................:.............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF..................................................................................... wr#ifiratr of ToutpliFanrr THIS IS ;'O CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by .. staller has been installed in accordance with the provisions of T-�' F' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..._ •-` ��' >............ dated_______________________________________________ THE ISSU NC OF THIS CERTIFICATE SHALL NOT BE CONST AS GUARANTEE THAT THE SYSTEh+1/Wl F CTION SATISFACTORY. DATE../..L2.Jl... Inspector._. ... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Z + .....................................OF..................................................................................... No......................� 'FEE. �E............. Disposal irks 0.1 ustrudion rruti# Permission i ereby granted ------ - '------ �C'r.---•-....-•------------•------- - ........................•-•-----------...........-•-----•----. -- to Construct or air ( ) an Individual rage isposal,Systemat ................... f Street ` as shown on the application for Disposal Works,Construction Permit No..................... Dated.......................................... . .. .� .� ••-- --.-• .................................................. r c� `/ r Board of Health DATE......................................d .......Z............................. !FORM 1255 HOBBS & WARREN_INC., PUBLISHERS a �. P 1-4 iLI,4 wATE� 1 , OC7C� M IN. L 0 T FfbmTty ;= ICIS' 4 MINIA)I M FPC)mPAL WA,,I�IE.u//�-i}a•'(fL."lPL�1Nj�►J'II\Jf_, �E%U P(L. oww oi`- I1�� F--A t`->lX.f�1 I DN:,, ' �'h,.Y-��. .. _ - «.m•.•r- �..... III., Cr IA Pr. ILL, J- .. U J 4/1 _ 1 51 z 3 � `O T 3 • ' 3 38 7 32 � rJ <' � uq f rr.s 33+ TEST V N 1 /vop J r S 'r7c' PALE .47 i 6></D 741 C.H. N M a pd'48 ItBEltv A'A. �n 44ORSE o > No. 1095106 G� �° Fr/SlEP C.f�.FND,TB.M. �� a�c�� ONAL1V E L, _ 63.4's r U°_ �r ,q=4 .o t7 G"7L_Q ST�,Qv./1? "✓ 4-"ILL 4 �A-, z77, EXISTING SPOTaEL'EVATIO 0 0 �KOF� CERTIFIED PLOT PLAN EXISTING CONTOUR--- 0 --- FINISHED SPOT ELEVATION o �« LoT.3 A Lt) Y'� ILL . FINISHED CONTOUR 0 y s H 4 o APPROVED o BOARD OF HEALTH �N��Ba�o� IN o.sua� SAAAS tA,0Ljl,#A. 3S* DATE AGENT SCALE � = DATE, 6 �� L RE06E ENGINEERING Ca IN gaps CLIENT 1 CERTIFY THAT THE PROPOSED E®1 RET9 E REGISTERED OS M0. BUILDING SHOWN ON THIS PLAN CIVIL LAND AA�M CONFORMS TO THE ZONINQ LAWS g � EN INEER R On.by-' OF 0ARN9TA LE, MA99. E-/ -PT > 712 MAIN STREET CM. sYp MYANNIS, MASS. SHEET e• OF 2 DATE E0. LAND SURVEYOR /VOTE /F E/7 A? 7,,WE-5FP7'/C TANS OR 20 FT. M//V. i4CN/NG ?/r ARE MORE TN I,-4/ /2"BE20W rRAOE� 4 24 'O/AMETEK C'ONCe-7 COVER S,yA L L BLE B ROu,GN T TO 4.T,4 O E.(:-;N "FXT CONCRCTt' 4�PYC P/PE f�+EAliy CA ST /RO/Y CO I/ER Sf 4 L L ! ,= USEO M/N. P/TCN /F/M DR/VElVR �' 86;s— COVERS �pE COVER CL EAN S'ANO IL 4.; T� � .• .•. ��'. 2"LAYER 4"CAS G1F [�B -?14B r.:b M/AN.Plr4OV" . • e I • . . . . . a e •e W �•.,.. D/ST. ASHFD 57t�NE /4'PEM>T SEPT/C TANK • • • ' • ° • � BOX . i e • 1 $ , • • • � �' .'• ��lc a•. e 1 • •EFPFCT%VC e` • • 3�4 - �2 • • 1 • OCPTH • • s v v WASNAFP STONE ...i /88 XPRECAS T SEEPAGE 7.9 f• 0 ,= .. -78 • o• • • • '• • • • • cr • p �•p (�/}G. GA o . . • • . • • • i • •s •c�L P�7 OR E4U/V, eR�'=&L EYAT/oNs p�rGG?7` 54 8 _ y . Fs/- �.5 /NYERT..AT Q"t/_/LD/MG '83. FT //VLET "-'PT/C T.4/NK � . 3 FT /O FT O/�!4/►9. __^ C SEE TABULATION ' OUTLET SEOTIC TANK t FT INLET D/STR/B//T/DN BOX 8Z•9 FT :SECT/ON.Oh . GROVNo ri�176R TAOLE 0(ITLETDI3-TR/BU7r'/ON mx$2.7 FT SEN/AGE G/SROSA L SYSTEM /lj/46T Lgs1CN/NG PiT SIFT TABULATION L EACH//VG A/T 3 T. SCALE : ��~ s -O. O//>/E/V.S/ON A DES/GN CRITERIA 01lV*N5/oN 49 ¢ FT. /'1/[/' NLI.WSZR OF BEDROOMS D/,9EN5/4N C Gi4R6AGAF 0/5P05A4 UNITS SOIL LOG So/L TES T TO7AL EST114A-reo o=Z0*V .33 0 G.4L./DAY SO/L TEST O/ SO/L TEST�2 [1tFUMBER 4F LdACNlNG PITS f`ELEK 8¢s �`-ELEY, �`F 3 OATS O� SOIL TEST 7�Z 0/ Z T S/•OE LEAGH/NG PER P/T 4)a PT. O —Z RESULTS /V/T/VESSED BY J. a o.rromLEr4CII//VG PER P/T 7k $0. FT PERCOZA-r l.)N MATE,*/ M//V//NCH TOTAL LEACH/NG AREA 6 SQ• FT. 7-0 C/L S� �''1 E' FWtCOL,.g770; V RATE�2 F � _ -7 1 RESERYEGEAG"H//V6 AREA Z-G 6 SQ. T. Z J ��Z�OF Mq, i►.saadl 7 '_ 1? L C F hf� rjo i Al 'ila`19874 RSE L EPA/NG CO /NG. � o � E KEDGE ENG/N F � °� No.10951 ,p Q�8TB� pQ` . o �` P' �� 2/[".'r; 7?:.� 7/2 )vlA/N ST. , yYANn//S, M.ciSS. N� SUR�E'yG�STE FSSIONAL�� NOGRovNt7 yv.4TCR ENCO[/NTEREp T,•ac -{-:: ..� DATE.9 fgcaa' Q .GM0 U/VD kVATE.P AT JOB ND; S 0 0 6,5 SHEET OF w 1. 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