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HomeMy WebLinkAbout0051 QUISSET ROAD - Health 51 Quisset Road Hyannis { A= .250-149 I�, TOWN OF BARNSTABLE LOCATION , p aj SEWAGE# D 6 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. � � C\ �Ct�.1+C, , St(0�6� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) p 7qLc (size) NO.OF BEDROOMS p K OWNER G. PERMIT DATE: I _�o I a 0 COMPLIANCE DATE: Separation Distance,Between the: Maximum Adjusted'Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ! A w � w 018, C i Commonwealth of Massachusetts o2SD— r�9 Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 51 Quisset Road Property Address t Yarbro `. O'er Owner's Name iequir don is Centerville V Ma 02632 8/3/2020 required for every � �(_1.�.._�. _..__._. page, Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information sk lg:�Iq on the computer, use only the tab Sean M. Jones key to move your Name of Inspector ---_ _...... cursor-do not _S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane _ m Company Address Centerville Ma 02632 City[Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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 8/3/2020 Inspectors Signature T 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. 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.7l26rz018 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page t of 18 Commonwealth of-Massachusetts === Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments r 51 Quisset Road Property Address Yarbro Owner Owner's Name -- __ _._......�_,__�._.__................._..__ information is Centerville Ma 02632 ,;,,,'; a;"8/3/2020 required far every ._ __.. �. Cit !Town �... _._._._........_.,._................�.„�. page. Y 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: The property located at 51 Quisset Rd Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 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. ❑ Y ❑ N ❑ ND (Explain below): t5tnsp.doc•rev.7126/2018 Title 5 Official Inspection Form:Sucsurtaca Sewage D'sposal System•Pape 2 of 18 V Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary y Assessments r 51 Quisset Road Property Address Yarbro Owner _.. - . ____- _..�_ Owner's Name --- -- information is Centerville required for every _ . _......_ Ma 02632 8/3/2020 page, Cityfrown State Zip Code Date of Inspection C. Inspection Summary (coat.) 2) System Conditionally Passes(coat.): ❑ 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 pipes)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: 1Smsp. -rev 7126co18 Titie s otfiaia€Inspemon Form,Subsurface Sewage nisimsai system.Page 3 of'18 Commonwealth of Massachusetts 48 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Quisset Road Property Address Yarbro Owner Owner's Name reformat+fo Is for every Centerville Ma 02632 8/3/2020 page. City/Town - —^ 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 9 to or less than 5 mg ppm, provided that no other failure criteria are triggered. A Copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You MiLst 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 151nsp.doc-ray 7t2612018 Title 5 Official Bnspec Lion form Subsurface Sewage Disposal System-Page 4 of t8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Quisset Road Property Address Yarbro Owner Owners Name -- --_ information is Centerville Ma 02632 8/3/2020 required for every _ page. Cttytrown State'y Zip Code Date of inspection-� C. Inspection Summary (coat.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %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 C.4. 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 15insp dec•rev.7/26MIS Title 5 Official inspection Form.Subsurface sewage oisposai sysiem•Page 5 of is Commonwealth of Massachusetts W -; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Cuisset Road Property Address Yarbro Owner Owner's Name information is required for every Centerville Ma 02632 8/3/2020 II' page, City/Town 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 C.4 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 C.4 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)] t5tnsp.doc•rev.7126=18 Title 5 Official inspection form.Subsurface Sewage Disposal system-page 6 of 1a CommonweaM of Massachusetts EEO_ Title 5 Official Inspection Form - Subsurface Sewage Disposal System form-Not for Voluntary Assessments P 51 Quisset Road Property Address `— Yarbro Owner Owner's Name information is required for every Centerville _ Ma 02632 8/3/2020 page. Citylrown ^� .��_._ State Zip Code Date of Inspection D. System Information y- 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): 33—0 gam-- Description: Number of current residents: 0--- Does residence have a garbage grinder? ❑ Yes 0 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 [I Yes ® No information in this report.) Laundry system inspected? ❑ Yes [D No Seasonal use? ❑ Yes 1 No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date 15insp.doc•rev.U2612018 Tole 5 Official Inspection Farm: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 _51 Qulsset Road Property Address Yarbro Owner Owner's Name informationquirefor is Centerville Ma 02632 8/3/2020 .required for every City/Town(Town page y 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 Now was quantity pumped determined? --- __...... Reason for pumping: -- - --- 15inap.dot-rev 712612018 Title 5 Official Inspection Form;SWSURaCe Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 51 Quis3et Road Property Address Yarbro Owner Owner's Name information is required for every Centerville Ma 02632 8/3/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool F1 Overflow cesspool El Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) 0 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 El Tight tank. Attach a copy of the DEP approval. El Other(describe): Approximate age of all components, date installed (if known) and source of information: original system installed 1983, distribution box replaced 8/3/2020 permit#2020-237 Were sewage odors detected when arriving at the sita? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: 0 cast iron 40 PVC [I other(explain): Distance'from private water supply well or suction line: feel Comments (on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp doc-rev 712W018 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 51 Quisset Road Property Address Yarbro Owner Owner's Name Information is required for every Centerville Ma 02632 8/3/2020 ---. --_— page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ED concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons 5" Sludge depth: _..-_ _..._._..........___ Distance from top of sludge to bottom of outlet tee or baffle 3' -- - Scum thickness 201 Distance from top of scum to top of outlet tee or baffle 7 - Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. *nW.dw-rev.TfZ 0110 Tille 5 Ortfrfal Inspertlon Forth Subsurface Sewage Disposal System•Page 10 or 18 Commonwealth of Massachusetts - Title 5 official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Quisset_Road Property Address Yarbro Owner Owner's Name information is Centerville Ma 02632 8/3/2020 required for every _ _._ page Zip cityrrown State 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: 'oaie��ry- Comments(on 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 t5imp.00c-rev.7/2mle Title S official Inspection Form:Subsurface Sewage Disposal System•Pape 11 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Quisset Road Property Address Yarbro __ Owner Owner's Name information is J a 8/3/2020 required for every Centerville-- Ma 02632----------------___-�— 02632_ _-._ Y page. CitylTown 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 9. Distribution Box(if present must be opened)(locate on site plan): niF Depth of liquid level above outlet invert ---- - - -- - --- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was replaced for inspection permit#.2020-237 t5w*p dot.•rev.71 WO!8 Title 5 Official Inspection Form Suosurfece Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposals System Form- Not for Voluntary Assessments 51 Quisset Road Property Address Yarbro _ Owner Owner's Name information is Centerville Ma 02632 8/3/2020 required for every _ ___.. ., ._.... _..:.. page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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: 1 ❑ leaching chambers number --- -- ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology- tsinsp.doc-rev.712eaof 8 filie 5 Official inspection Form:Subsurface Sewage Disposal System•page 13 of le Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Quisset Road Property Address Yarbro Owner Owner's Flame information is Centerville Ma 02632 8/3/2020 required for every -� page Cit y!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.): Leach pit was dry at time of inspection with a stain line approx 3.5' from bottom 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.): t5insp.doc•rev.,70=18 Title 5 Official Inspection Forth SubsiafaCe Sewage Disposal System•Page 14 at 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 51 Quisset Road Property Address Yarbro Owner Owners Name information is required for every Centerville Ma 02632 8/3/2020 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.): t0insp,dw.-rev.7mmia Tiftle 5 Official Inspection Form:Subsurface Sewage Disposal System-Pap 15 of 18 Commonwealth of Massachusetts -: =- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Quisset Road Property Address Yarbro _ Owner Owner's Name _ information is Centerville Ma 02632 8/3/2020 required for every —._.--------------- pege City/Town 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 K_Ed A-k D T�i Z7' 2 3S"� RZ � C32- 3Z 3 91`� (33 3?'6 t5insp.doc•rev.7/26/2018 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts -t Title 5 Official Inspection Farm -- - 11 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Ouisset Road Property Address Yarbro Owner Owner's Name information is Centerville Ma 02632 8/3/2020 required for every _.,_..._._..._..__�__�.._._... _ _..._.._. page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: -pate - —- - --- M �------ ❑ 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5mp.doc•rov.7126=18 Ttlto 5 Officof Inepection Form.Subeurfoce Sawago Diepacat Syetom•Page 17 of IS Commonwealth of Massachusetts W,= Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Ouisset Road Property Address __-- Yarbro _ Owner Owner's Name information is Centerville Ma 02632 8/3/2020 required for every page. Cityrrown 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 t5insp.doc•rev.7fZ8f iS Title 5 official inspection rorm.Subsurlace Sewage Disposal System•Page IS of IS No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for ]Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(,,/Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Addressor Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel I staller's Name,Oddressss and,Tgl. esigner's Name,Address,and Tel.No. Type of uilding: f Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow(min.required) Ir_ gpd Design flow provided ft n gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil n Nature of Repairs jrAlterations(Answer when applicable)` �� �n 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 Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date %o — Application Disapproved by Date for the following reasons Permit No. 9_0 175 7— Date Issued �� �� ,..:—Ar—3...;a7r�`:Y.'1 r ,�•v':.i•.r� ..'r,`7,...,-c.,:y,,:... ,� -...-s. mrw, a ,..+`•...'.�C,+"�.,w ,..vyr. :.{ ".:...+.."'.�•.w.R�7'-f ' ," Y�i`+��.'.,� .1'KL.+n y:�,[%.+te' +.m•.. w No. Fee 7 , THE COMMONWEALTH OF MASSACHUSETTS Entered it computer: Yes PUBLIC HEALTH DIVISION:',. TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Misposat *pstem Construction Permit Application for a Permit to Construct( ) ]Repair(/Upgrade( )'Abandon( ) [:]Complete System Individual Components Location Address or Lot No. V ESQ. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 11316`-1 tic Installer's Name,Oddress,a}td Tel.k a( (ham esigner's Name,Address,and Tel.No. Type of wilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures w Design Flow(min.required) gpd Design flow provided gpd Plan. Date Number of sheets Revision Date Title "Size of Septic Tank =Y Type of S.A.S. Description of Soil.; ..r Nature of Repair=QrAlterations(Answer when applicable) ~` T �� ©) W ' C _. Date last inspected: ` Agreement: .The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in y accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. - ' Date Application Approved by Date �0 Application Disapproved by Date for the following reasons ` Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS. ' BARNSTABLE, MASSACHUSETTS •�. Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) ` Abandoned( )by _� IiC. at ,3",n N�S e k QL ek t\6, has been constructed in accordance with the provisions of Title�5 and the for Disposal System Construction Permit No. dated Installer l '^` qT L1,4 U Designer r #bedrooms Al Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will fiCfiornas desi " r t\ Date Inspector No. i a�V 3 Fee _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE;MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at � ��\` Q, S� Q, /t 1\ and as described in the abov%Application for,Disposal System ConstructionT'ermit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions.- Provided:Construction must be completed within three years of the date of this permit, Date .. a ' Approved by COMMONWEALTH OF MASSACHUSETTS u d EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' a DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPEC TION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 3lo Property Address: 6�,4 ' Owner's Name: / n0441 A Owner's Address: G NO �.e� ev,' r c.1,c. CD of Inspection: a O / — i Name of Inspector: ( lease print) PO ,� f =- Company Name: il/✓i'o r_-: Mailing Address: o QoJC . ' i41 � Telephone Number: o CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function anclsmintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuan�to Se on 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 01 0 The system inspector shall sub ' a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARy ASS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI ESON FORM TS PART A J CERTIFICATION(continued) Property Address• ti s je � j � Owner: �0�o Date of Inspection: g OS Inspection Summary: Check A,B,C,D or E/ALVN-AYS complete all of Section D A. System sses: I have not found any in fonnadon which indicates Orin 310 C1vIR 15.304 that any of the failure criteria exist,Any f��criteria not evaluated are indicated below.described in 310 CMR Comments: ents: B• System Conditionally Passes: 1'1/ One or more system components as described in the"Conditional repaired The system,upon completion of the replacement or repair, Pass"section need to be replaced or as approved by the Board of Health„will pass. Answer yes,no or not determined(Y,N,ND)in the explain for the following statements.If"not determined"please T'e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is strut unsound,exhibits substantial infiltration or exfiltration or tank failure is existing tank is replaced with a co 1 ' ep imminent.System will pass inspection if the *A metal septic tank will ass �g s tic tank as approved by the Board of Health. indicating that the tank is less than 20 y�old is available.it is structurally so d'not leaking and if a Certificate of Compliance ND explain: Observation of sewage backup or break o ut or high static water obstructed pipe(s)or due to a broken,settled or uneven distribution ox.S s e the distribution box due to broken or approval of Board of Health): System will pass inspection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumpin an q pass inspection if(with approval g more than times a yeYearP due to broken or obstructed pi e(s).The system will of the Board of Health): broken Pipe(s)are replaced obstruction is removed ND explain: T41. i^anon*inn�nrn�!./�c/�nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: / VI®641 a Date of Inspection:_:::: oZ$ i7 S C. /Fur er 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: T:rio rncnanrinn r.,,sir�i�nnn 3 ' Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �/ QV(lS.-Ce� `� ri e✓� Owner: / ��0w1 ra S Date of Inspection: 33 p!'j D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Z/ $ackup 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 ,06gged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool �/jrquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number 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. VAny y portion of a cesspool or privy is within a Zone 1of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) s o _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title G lnc»antinn Rnrm 4/1 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Q�I I jr'e-e Owner: i--! o l4s Date of Inspection: qo?t>? p� Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes o 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 recentlyart o or as p f this inspection? 4' / Were as built plans of the system obtained and examined?(If they were not available note as N/A c/ ) Was the facility or dwelling inspected for signs of sewage back up? ✓ — Was the site inspected for signs of break out? v — 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? v — Was the facility owner(and occupants if different from owner mai/ntenance of subsurface sewage disposal systems `? )provided with information on the proper The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes o 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(3)(b)] T;0. G lnenartinn Gn�m �ii�nnnn 5 Page 6of11 J OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2 Owner• ✓�LO��off. Date of Inspection: per• RESIDENTIAL F OW ONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): -? DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 7c Number of current residents: d Does residence have a garbage grinder(yes or no): /60 Is laundry on a separate sewage system( es or no):/rib [if yes separate inspection required] Laundry system inspected(yyes or no): (� Seasonal use: (yes or no): iV 10 Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): " Last date of occupancy:,- r- L,I.-e✓ - COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: 1992— e're", Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T2 P'PdF 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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if own)and source of information: Were sewage odors detected when arriving at the site(yes or no): T tlu G Incnvrtinn Rn�m 411 6 Page 7 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: G U(fk Owner: / vlOoe wt s e✓vi T__!�fj O�6'3Z Date of Inspection: 07 BUILDING SEWER(locate on site plan) Depth below grade: r // Materials of construction:_cast iron _gyp PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) ' P ) Depth below grade: Material of construction:_✓concrete metal fiberglass—polyethylene —other(explain) — If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) i Dimensions: Sludge depth: oZ Distance from top of sledge to bottom of outlet tee or baffle: �� ✓ Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom�f��ooutlet tee o baffle: (v How were dimensions deternuned: o/e � �2yI e, Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels le 4 as dated to outlet invert, evidence of leakage,etc.): _ ti.'� ,N ✓10 /! ���/ / TtG � � � 7�t✓'!,�. � q H � a14 C� GREASE TRAP: / locate on site plan) Depth below grade:— Material of construction:—concrete metal fiberglass_polyethylene other (explain): — — — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): T;H. G Incnartinn All S/7M() 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: QU sf L`J_ �_A'4 .evt Owner: 7"Apk Date of Inspection: 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_1]olyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX; (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: V7 O✓1/41 A Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage i or out of b x, etc.): �.G��i�/. � So%�s ✓r/� .fie�•�.t. PUMP CHAIMBER:<1✓ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: L/ 6U r✓a Rj Owner: o>M a if 'Ni 4 Date of Inspection: 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: �p leaching fields,number, dimensions: overflow cesspool, number: innovative/altemative system Type/name of technology: Comme s(no a condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc. : e 5-4a,Li Of 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 or no): 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.): T:fio a rncnor*:.. �,.,, sir�i�nnn 9 Page 10 of 11 � 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J�l QU LCk / Rr.J Owner: / � o V1^j / Date of Inspection: 9 1 /� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. AL- 3j ' T� 741. C In-,finn 17- 411 VIOnn 10 r Page 11 of 11 ' 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (�14 u.X4 l� XJ e erg Owner: �— 4 ,"1 -n Date of Inspection: d� o5 SITE EXAM Slope Surface water v Q Check cellar Shallow wells ` of Estimated depth to ground water 3p3feet CO 6A3 9,3Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: rved site(abutting property/observation hole wit 150 feet of SAS) Iffhecked with local Board of Health-explain: 1,:--c,"�5- Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: To% 0 00 0 i p � Od I 1 . ®10 0 '9 � I Grow^ 37 3 Titlo C ►ncr�crtinn L7nrm �ii si�nnn 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -1 Not for Voluntary Assessments r Property Address Owner Owner's Name information is �h k'i yi At, Oa)b 3a ®a � f required for State Zip Code Date of sp tion every page. City/Town P 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 A. General Information . I / A✓1 forms on the computer,use 1. Inspector: only the tab key to move your y p se.,// cursor-do use the retut m Name of Inspector Y• � l�1 Q �� Company Name Company Ad:ra s��g� City/Town State Zip Code /,So? 7 7S Telephone mb License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority "i jv�zi 0 Inspect is 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. I � I I 1 15ins•09r08 Title 5 Official Inspection Form:Subsurfac Sewage Disposal system-Page 1 of 17 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments lip Property Address ov Owner Owner's Name information is / „� ��I� ,l 1411 9 required for I/e every page. City/Town State Zip Code Date off ns ection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System sses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 exbltration 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): t5ins•09108 Tille 5 Official Inspection Form:Subsurface Sewage Oisposal System•Page 2 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments S-/ C4 Property Address 14a4ro Owner Owner's Name }/ 7 information is required for every page. City/Town State Zip Code Date Iff Ins6ection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)�are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to:protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•OV08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts rh Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is le - 0��� !pAt//17 required for ' every page. city/Town State Zip Code Date f In tion B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters LVJ / due to an overloaded or clogged SAS or cesspool ❑ 2/ 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/z day flow t5ins•09108 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 Q1!tl:�l� T 9 Property Address / GDP'/dam Owner Owners Name1� q� �� /" information is o�� do 7�required for State Zip Code o In ction every page. City/Town B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or ❑ �bstructed pipe(s). Number of times pumped: ny 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. ❑ [l�Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ L ' 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 aMa monia 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.] ❑ ®/' T e system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. inns•09i08 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 9 t4 10104 Ad Property Address Owner Owner's Name / �reformation is C� Ile L—-� 04?) h e required for every page. Cityfrown State Zip Code Date of I nsl5ection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No Q� ❑ 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. L�J' ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 15ins•09108 rifle 5 Official inspection Form:Subsurface sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Officiall Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address a,^ , f� Owner Owner's Name / information is "�4 required for /� / every page. City/Town State Zip Code Dat of fnipection D. System Information Description: rl) l®oo 6-4 11n.7 i Number of current residents: Does residence have a garbage grinder? ❑ Yes �o Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ["No Laundry system inspected? ❑ Yes ET"No Seasonal use? Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date CommerciallIndustrial 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 i Water meter readings, if available: [Sins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts U4Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a'A Property Address Iv Owner Owner's Name information is �, %6 �. �� Q,� c required for State Zip Code Date o Ins ection every page. City/Town 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 Sy 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•09V08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 17 i Commonwealth of Massachusetts Em Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Sl Property Address / A✓vJ/� Owner Owner's Name /_ information is V1 6 �— �o `7` �a required for every page. City/Town State Zip Code Date of InslIection D. System Information (cont.) Approximate age of all co np n nts,dte installed known) and source of information: Itl Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): a Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Materia 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: �x Sludge depth: L L15,ns•09r06 Tide 5 Official Inspection Form:Subsurface sewage Disposal system-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form . Not for Voluntary Assessments �i PL41jyd- )qcl Property Address ad�r-v Owner Owner's Name information is � /a/`� //` 0,4 required for L every page. Cityrrown State Zip Code Date of In pection D. System Information (cont.) Septic Tank (cont.) "// Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments (on eumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, e—viddnce of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date _ t5ins•09foa T'Poe 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 • �� (�Iu�SSe-7' Property Address ov Owner owner's Nam j/ information is ��,� �/l� lob- y required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dace Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins•OW8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r— Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address E)l a(A s5R-- 9d q.dbry Owner Owner's Name information is a,,' �f /� O�d /U k k required for / _ 4L every page. City/Town 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 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.): 6.1& )� 1---e,ve 7 W C:�S' Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition iof pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•09M 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 a� Property Address Owner Owner's Name ) information is required for r�N�+< ,14, 02b a lo mllt every page. City/Town State Zip Code Date of In pection D. System Information (cont.) V Type: DI t f leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition.of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ti '1 l / r/ r�- 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•09108 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 9d Property Address G>✓ 0. Owner Owner's Name information is �'e �� o �- /0 required for State Zip Code Date of Ins4ection every page. Cityfrown D. System Information (cont.) Comments (note conditionbf 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.): f 15ins-09/08 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 / Wd5 — Property Address Gi ll d boev Owner Owner's Name � information is /� /" W 101W 0 V required for �1 every page. City/-Town 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 ublic water supply enters the building. Check one of the boxes below: hand-sketch in the area•below ❑ drawing attached separately r 141 c� r 93 -- 3Y Isins•09r08 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 Property Address 14 rv': Owneinform Owner's Name inform ation is required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet / Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from!system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: plel'l 1- i e.5 � &/--- ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USES database -explain: You must describe how you established the high ground water elevation: AS- I s- 146 k-Z. ......................ic, ✓J S ! G u J " Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins,09/08 nue 5 official Inspection Form:Subsurface Sewage Disposal system-Page 16 of 17 I Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name >� information is `: ' /j Od 6 Z 411P required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist 2--*1'4nspection Summary: A, B, C, D, or E-checked [r]Inspection Summary D (System Failure Criteria Applicable to All Systems)completed VSY mInformation — Estimated depth to high groundwater ketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•o9fo8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 . 1♦ ,1 o Z- COMMONWEALTH OF MASSACHUSETTS i. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR RECEIVED \OCT 2 2002 TOW BARNSTABLE N�L.TH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Ch u rsse MAP 25 O v �r'r✓r c' U 3� PARCELI �- Owners Name: LOT ~�~ Owners Address: �/ 2 Date of Inspection: r v Name of Inspector.(lease print) Company Name: �ir/✓1�� — rL—CC%f Mailing Address: - Telephone Number, ' ' — CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on mN training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation b%-the Local Approving Authority_ Fails Inspector's Signature: �Gv � �, ' 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' n Property Address: S U� Owner. oel Date of Inspection: iv t' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst asses: I have not found anv information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system.upon completion of the replacement or repair.as approved by the Board of Health.will pass. Answer yes.no or not determined(Y.N.ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurallN unsound_exhibits substantial infiltration or exhltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound.not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain.- Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or*due to a broken. settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a vear 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 e obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:, ddress _� A � �9 Owner. ' 11 a4 r� Date of Inspection: 9 /v D C. Further Evaluation is Required by the Board of Health: /Y Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supple 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 laboraton•. for coliform bacteria and volatile organic compounds.indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: &C 4 l Sjc' Owner.J7 16 r . Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool c/ 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 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ c/ 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. A4Anv portion of a cesspool or privy is within a Zone I of a public well. /,Anv 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] /�//,0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CNM 15.303•therefore the system fails.The system owner should contact the Board of mi Health to deterne 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 g gpd. pd to 15,000 You must indicate either"yes"or"no" to each of the following:. (The following criteria apply to large systems in addition to the criteria above) yes no the system is witlun 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supple the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"ves"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 pe n. large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNIR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Jr OW15kl a , Owner. A/1`1-'; Date of Inspection: 9 f Ica Check if the following have been done.You must indicate`Wes"or"no"as to each of the following: Yes -No Pumping information was provided by the owner,occupant,or Board of Health ZWere anv 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 j� _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) v' _ 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 occup ants pants if different from owner)proNrided 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: Ye S no _ Existing information. For example.a plan at the Board of Health. Determined in the field(if anv of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 4 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:A� 4 .4 r S Owner. Date of Inspection: G FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: U Does residence have a garbage grinder(yes or no): &L' Is laundry on a separate sewage system(yes or no);t-O [if yes separate inspection required] Laundry system inspected(yes or no): 4!17 Seasonal use: (yes or no):/�c:' Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):�'- Last date of occupancy: i le t COMMERCIAIJINDUSTRIAL Type of establishment.- Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/sgft-etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings.if available:. Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records J Source of information: r "`'/"z'C Chi— o Was system pumped as part of the inspection(yes or no): /VZ) If yes.volume pumped: gallons—How was quantity pumped determined? Reason for pumping: T1P,E 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) 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 or no):&� Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: Gnu t fe � A1 _vl ✓ L�C Owner. Date of Inspection: p,L BUILDING SEWER(locate on site plan) Depth below grader /9 Materials of construction:jZcast iron _L46 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints.venting.evidence of leakage,etc.): SEPTIC TANK` (locate on site plan) Depth below grade: _ Material of construction: concrete_metal_fiberglass_polvethvlene _other(explam) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(ves or no):_(attach a copy of certificate) Dimensions: �X Sludge depth: 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: 11-6)--Sc w -� Distance from bottom of scum to bottom of outlet tee or baffle: .vv Sc.oz✓'l How were dimensions determined:zif/I r r c4nVic 6, Comments(on pumping recommendations. inlet and outlet tee or baffle condition. structural integrity. liquid levels as related to outlet invert.evidence/of leakage. etc.): / TG��� � �� !/lfiy?.G nt-7✓"1 '7iili . � f�v Y' ��.n� �7�. T"r�- J�7 ` , ( GREASE TRAP:/ Oocate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polvethvlene other (explain): Dimensions.- Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition. structural integrity. liquid levels as related to outlet invert.evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6201-od 1 � opt 63� Owner. 1 U� . Date of Inspection: be I 0 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): pumping: Date of last pu Comments(condition of alarm and float switches.etc.): DISTRIBUTION BOX ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: I eLv�c� Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover.any evidence of l ge into or out of box.etc.): PUMP CHAMBER (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber.condition of pumps and appurtenances.etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �� (X in 1 r. .j rv� 3� Owner. Date of Inspection: Y (c e .. SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: _ � T7 leaching pits.number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,.number: innovative/alternative system Type/name of technology: Comments(note condition of soil.signs of hydraulic failure.level of ponding,damp soil,condition of vegetation. etc.): % 3// CESSPOOLS: (cesspool must be pumped as pan of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil. signs of hydraulic failure. level of ponding_condition of vegetation.etc.): j 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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J � (SSef YQ Owner. Date of Inspection: <� SKETCH OF SEWAGE DISPOSAL SYSTEM . Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building_ i i 3j I 1 " n Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: SSz c� Owner. Date of Inspection: io SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 3 feet Please indicate(check)all methods used to determine the high ground Rater elevation: Obtained from system design plans on record-If checked date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) 17 Checked with local Board of Health-explain. /1%�.�7<- Checked with local excavators.installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: - —-- l `/? c 7� oc: j C' C L C, f I C: l 3 b ��w -��� V-) A-3 I _ f 1 H W� flu Isoc N e t 401 INZ ic mc W � N � O � r O W � O A C �� /Y C9�� �i ¢ G", -, r G � . � : (�• / _ ,'r`� ^ � t � �,� ` ��. v:',r \. 1- No........ ........................... ;a. THE COMMONWEALTH'OF MASSACHUSETTS BOARD OF HEA T GC OF.... /..�.7.1.. ..........-- I Applira#ion for Disposal Works Tonstrurtinn Frrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at* ...... ......._ .... .................................. R........._..... ......... �,oeation-Addre Gr Lot No.r 1 1 ) ..-.. - Address •• ` q Installer Address Q Type of Building `� Size Lot_Z49. a C `q. fee V Dwelling—No. of Bedrooms.---•-------•......•---•----- P Showers g ( ) ,.., __..__..__..Ea Expansion Attic (sar a e Grinder Other—Type e of Building No. of persons.................. a YP g --------•-•----------•-•--•- P � ) Cafeteria Q' Other fil tg=s ................ ____ Design Flow............ .... .................... lions per person per day. Total daily flow__._.... � gallons. WSeptic Tank—Liquid capacity�b allons Length................ Width................ Diameter................ Depth................. x Disposal Trench—No..................... Width............. Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No:..........1--------- Diameter....1V_./e? . Depth below inlet.................... Total leaching area J�._Sq. ft. Z Other Distribution box ( ) Dosin tank ( _ z `-' Percolation Test Results Performed by . � "` � - .. Date--- `,7d ,1...........� �4 Test Pit i�o: 1....... _ ._.. inutes per inch Depth of Test Pit..... Depth to ground water_.__. ` . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ®' Descri ti9n o f oil------.. '!. ----- 1 --. 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 TI"T is 5 of the State Sanitary Code—Th undersigned further agrees not to place the system in operation until a Certificate of Compliance has be i u d t oard of healt . gned-- 1410 ApplicationApproved BY--••--•--- ... ............................................................................ ----=-°�--•--...----......,.......... Date Application Disapproved t following reasons----------------------------------------------------------------------------------------••-••------------.------- -----•-•------•-•-------. •--•---•---•------...-•-•-•---------••-•....-------- Date PermitNo.......-.....................-........................... Issued....................................................... Date FEig... No.......... ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............0....... .................... Allpfiration for Disposal Works Tomitrurtion Vamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Systemat: zp........... ................................. -----------'�*..................................................... --LDtion-Address-— 0 7o't '0-.j>!; ................. ---1... ........ .................................. Address Owner Add....... ....... . .... ..iz2 ..........ljz------i?24 Installer Address Type of Building Size feet Dwelling—No. of Bedrooms............................................Expansion Attie Garbage Grinder /� Other—Type of Building ............................ No. of persons.__..________._.____._____._ Showers Cafeteria P4Other fixtures ................................................................................................................... Design g Flow..................;?, ................ ,,,7. 1lons per person per day. Total daily flow..........3..3.0......................gallons. 04 ./Septic Tank—Liquid capacit� .02�`;,Qlons Length________________ Width..-__..__.____.. Diameter__-__-__________ Depth_______..___._.. Disposal Trench—No..................... Width..............;r..... Total,Length____________._...__. Total leaching area....................sq. f t. Seepage Pit No...........1........ Diameter____., Depth below inlet____________________ Total leaching area� ft. z Other Distribution box Dosing. Date......., Percolation Test Results Performed by ....... / e��. ..........Test Pit No. 1.....f-�.-Z-minutes per inch Depth of Test Pit__.__.17........ Depth to ground water_____...'.":__.__'.:_. ................... Test Pit No. 2................minutes per inch Depth of Test Pit.____._..__________. Depth to ground water_-______-_______________ a ••--•--•-•••-----•--•--------------•-----•._..._ ..... .................... 0 ..................Z---------------------------- ------------------- Description of Soil........ :L........ ................................................................................ . .............. . ..................................................................................................................... U ......... ........... 'zip...................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...........................................................................I........................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TILT112- 5 of the State Sanitary Code T undersigned further agrees not to place the system in operation until a Certificate of Compliance has bep I U d t oard of healt!�, "Signed... ... ..... .. ................................................... ApplicationApproved By-..g............rele ... ................................................................. ............ ... ... Date Application Disapproved ,r t ollowing reasons:.............................................................................................................. ........................................ ..... ........................................................................................................................................................ Date d PermitNo......................................................... Issue&....................................................... Date J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... ............................OF.................................................................................... 01 T rfifirate of Toutpliatta%Ur iTO e RTIFY, That the Individual Sewage))isposal System constructed r Repaired T IS ),o b ......... ....... ........................................................................................... ... . ................... ......... ........ ------ y V:7/ a: ......... . ..... a�. .. ......... ................................................................7------- --------------------- has been instal ed in accordance with the provisions of T11T LE 5 of The State Sanitary Cod S 'cribed in the application for Disposal Works Construction Permit No...f--- ............. dated- .................... THE ISS UANC;E 0 THIS C C�ON I CERTIFICATE SHALL NOT BE � STIZIJED AS UA ANTEE THAT THE SYSTEM WILL A 0ION SATISFACTORY. DATE--- ..L. Inspector... ... .. .......................................... ........... .. ..................................*------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................................0 F.................................................................................... No.. .. FEE­�V............... Permissionis hpi;6'y granted..... �<-4.. . ................................... -/........................................................................ ."Vid Dis Sal 7 to Construct air a ge S9, /* S yr-� -n at No. ........ ----------- ......................................... ................. Str . I-Au o the a/pi Disposal Works Construction ]?�m fit No_____________________ lxf'c .......... as shown on the 1* ion for ............................................ .. ..................................?............. oar /of Health DATE...... ..... ............................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ft SCALE - NOT TO SCA'-L.�" /8"SrD�L r W4 r fir. MH COVER a:. .4 C.I. PIPE .„ N --"---- -*--- - 4"`BIT. FIBER PIPE TIGHT JOINTS _- __ FLOW L INE JI(/rL E r t EVEL ,• � Tom_ f� . e D*FLLIN �e� _ j 10 • „i j 'R C.I. TE£ C i / � AlilSrANOARD PRECAST }}(�••`��il^�•_�� e—w...r•.- 1' �----------= it., d , G ;+. f CONCRETE;'p_VGALLON �. ` } SEPTIC TANK ' �,. D/STRISUTION BOX � f ro BE INSTALLED ON , LEVEL, -STABL F 84 SE cIt SEPTIC TANK M BE INS rA L L ED 62AI R LEVEL. , SrA8LE BASE f` rn 2 - //8 TO I/2 WASHED PEASAONF_ L f-<iCHla',l�,. PIT ALL AROUND FREE OF IRONS FINES S_r TL? Ei/' E- ,EI - , AND DUST /M PLACE 1 ` 8fir*ICX t9 AIORrAR CG"Ji?E S .T/`4" ro `-112"' WASHE-D CRUSHED r AS RFLA/IRED TO BRINGSTONE ALL AROUND ' COVER rO I;RADE, 24"C.I, MH COVEH � IRG�NS FIMES.4id0 fiLrS FREE MACE. A,4110 FRAME , 3 • u S . y 'Sy ''rt r.- 'i ,t'. Ps..� ":, .e .'.w,^^`,:.,:a•,••........�.......... _..— - ..-.�.._... _^ µf —' ., ': 3 `.1 t.... A�.r'f !;A. 4..° PIT SEi./'h I ! w . A IL i�ff�E f 1. CONCRETETO BE 400E PSI ;8 DAYS o r t 1 I�JFi P E� WITH 6' x 6� NO.6 GA, W,' m. z e e,.. x, ��' ;. �.^•. ; { i-�; � 3. 2' t1IVG -�' SECTtUIdS ARE AVAILABLE FOR E:t�.'#'EF? 3EPTH RLECUIP.EMENT:�. I P 1 �1a�+ �aT;i, pr' ►T GG, _! I , . i�ESE:P �7t n tiF _3 OPENING rs 'rH 4-I,i8" � ^�' �,r. I' - J $ OUTER DIAME T'E,' 8 VOTE EXCAVATE TO �.�.E JATkQh! .. F I-3/4 INSIDE D/h METER ; REQUIRED TO REMOVE ALL LOAM .4N CL A'! 6E�dEr�TfI PIT REPLACE: E:XC A,'�JFTED !AltaERIAL WITH CL'E N :�,At2. z; GRAVEL TO DESIGNED -PA L - m ! r _. z v 6" 6' ' hh ; / r.7_ �" ,,( g tr! 1 . rN/A+. EFFECTIVE DIAMETER ¢ Y + Y f tAIOT TO EXCEED 3 rIMEs EFFECT/Vt- DEPTki I b J - _- •�•w WA/"ER rABL E ( j BERG. RATE , r : 2� MIN, i IN . � EQUIPMENT TO Ruin OVER SYST1~►v�. ' . '? � 4 - � N© HEAVY _ SEPTIC TANK DISTRIBUTION BOX LEECHING, FITS T!i TEST E3`f: �,�.a L)�G N � � ���t./N� A GL u 1 t c i�•, it p,�j�J4G,� , PRECAST REINFORCED CONCRETE UNITS WITNESSED RY: .ilk -i It. i A G G' 4 tom° . , +�f } .. ALL SYSTEM COMPONENTS SHALL BE, I" S'i�r t.I`Ct I?` ACC. :EtC1+ICF TO REVISED TITLE 5 OF THE STATE ENVIRt l�dMENTAt- CCDE , ,�s. 1 'TEST PI' <:�R EL. �;v DATE __._ ' a p'J MINIMUM REQUIREMENTS FOR THE S€ SSUFACE D+`5P0SA � F ~., TE T Pt`:" Iy4C_! TEST FIT NQ. 2 SANITARY SEWAGE EFFECTIVE' JULY -�-} ANY '�? PLAN MIDST RE __'7 0 �) N CHANGES THIS BOARD OF HEALTH. _ .. A. BOARD HEALTH TF 6,3 r �E A� F'I �SH A�.. � -.•�-+.�- . -�«., 1 �� tax. ., ..,.. _ . P�� � I IA,.�i t a a .Tf PITCH ALL SEWER Llr+r[KJ 1t4 / �$i . _..r"t•,[- , •4`i_ ,OTHERWISE, .- .� DESIGN DATA ;. BEDROOMS._ _ ._- - DISPOSAL.— EST, TOTAL DAILY E F F. _r_wr_ ' `•' ' _GAL.S SEPTIC TANK �' : ww , _.. _ SIDEWALL. AREA ''�: GAL.i SQ. FT: ;, � �2 R WOO r.: t BOTTOM AREA w_ _ r' _GAL JSQ. FT. WAGE `< ` �'�} . / " �s. Lry EXt rIi14ry GRADE chi' �.EACHitdG REQL!IflEO �- SQ-FT. -� .. ( ACTUAL LEACHING AREA !E �: - FT• FCC FINISHU-4 ;,RAGE SQ. (-, rT y �,c-i x_J 1.� JI, "E' � t2 ,, r fl.,:O tom. J INVERT ELEVATION.., _ �ii% -�..r� CI LAMES ( I C WATER SOURCE.' ____•__. _.._ - ---� . __ �.__ _, _ � `.�` � � `� � �: r _<; �a �:..`�`' .�^A C, � s PROPERTY LINE � ry;� Ny. � •� PLAN REFERENCE ' .� m t _ . *�, _ SCALE AS INDICA J MEAN HIGH WATER },� 1 DATE / OR ---•- -- A E R �to �_ �^.�.` „ � `��' ��. E D AT �'�,:,L`�`�' •.,_. BEtVGN MARK DATUM: y' •o _ _ _ L 3 MARSH I♦ :.. ., r: _ ," WM. M, WARWICK 9 ASSOCIATES =L < ►1_j I_ ; IJ 101 j — I i A.A- IS, 12 r7l �- BOX 8U! — NORTH f'AL MG}UTH _ (` s7c•,��'`' MA SSACHUSE r T r' 025,56 may.