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HomeMy WebLinkAbout0103 REGATTA DRIVE - Health 103 I+�GATTA DRIVE,HYANNIS :`r A 1 i Commonwealth of Massachusetts W ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;;V 103 Regatta Drive Property Address 'Nicholas Laham Owner Owner's Name information is > required for every ale Alan MA 02632 t` page. City/Town State Zip Code Date of In ','spect n t +� 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. i' P! Important:When A. General Information c filling out forms ��.�"' on the computer, use only the tab 1. Inspector: key to move your e cursor-do not Renso Hidalgo , use the return Name of Inspector key. PKM CONTRACTORS, INC. rab Company Name 313 Hokum Rock Road Company Address Dennis MA 02638 City/Town State Zip Code 508-385-5993 13812 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Tit le•5 10 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑VNeesrther E a tion by he Local Approving Authority In ector's Signature Date ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the . report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. **This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the'same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G9M 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) VInspetion Summary: Check A,B,C,D or E/always complete all of Section D A) m Passes: ave 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: I ❑ 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Regatta Drive M Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No z❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool S 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 less10 . ❑ than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Regatta Drive 'M Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. 1 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 11 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 an large Y 9 Y P Y 9 system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 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 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 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 El ❑ V / 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)] 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts 1JAW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Regatta Drive M Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection D. System Information Description: Its -�1 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection No information in this report.) Laundry system inspected? Yes es ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail 2017— 120,000. 2016— 191,000 Sump,pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No f. Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type f System: Septic tank, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): a t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Ap o imate age of all co m nents, date installed (if kno n)and so a of information: 46 Iq q 9 TA 1►��c �. Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): i I 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.): Uri �� Ali r �� ar• Septic Tank{�cate on site plan): r Depth below grade: feet M erial of construction: concrete El metal Elfiberglass El polyethylene El other(explain) 1� If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No Dimensions: l - Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Y. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle - �- Scum thickness �1\ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle J How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I 0\1 OAA. 4 jL 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No , Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M , 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert —� 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.): b �V A VIOlfN dw 1rAV ► � S lut LJIU -� 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.): r * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan;excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts N = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ 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.): <"Q-rv\, U 16 AA& Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I - i O � 0 y 3 39 3 . y 3M, Z3 5-7 v r .. Commonwealth of Massachusetts W Title 5 Official Inspection Form Vk - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately I ` X Y V t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet PI ase indicate all methods used to determine the high ground wat r el vation: Obtained from system design plans on record If checked, date of design plan reviewed: Date , ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: r 6 S ennVbr,�� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 103 Regatta Drive Property Address Nicholas Laham Owner Owner's Name information is required for every Centerville MA 02632 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information'—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t t5ins-NU Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title. 5,eOfficial Inspection Form Subsurface-Sewage_Disposal-System Form - Not for Voluntary_Assessments.__ 103.Regatta Dr Y'S Property Address' JuIianiia•Biega Owner Owner's Name information is �y(�1�Y6 Centerville- % Ma 02632 12/16/15 r-rj required for every. 1C.". page. City/Town VState Zip Code Date of Inspection - r��1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way:Please see completeness checklist at the end of the form. _ Important:When filling out forms A. General Information �4 913yy on the computer, use only the tab 1. Inspector. key to move your cursor do not Michael DiBuono use the return key. Name of Inspector ' DiBuono Sewer and Drain rab Company Name 8 Johns path Company Address _ S Yarmouth MA 02664 City/Town State _ Zip Code .`508-364�-9587 S113522 Telephone-Number License Number cation 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,Evalua "on by the Local Approving Authority I _ 12/16/15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system,or' . has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Y Commonwealth of Massachusetts f Title 5 Official Inspection Form X it . Subsurface Sewage'Disposal System Form - Not`for Voluntary Assessments 103 Regatta Dr - Property Address --.--.Julianna-Biega- - - Owner Owner's Name >; information is required for every Centerville Ma 02632 12/16/15 page. CityFrown State Zip.Code Qate.of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E%always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level: The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. Sy-s-tem Conditionally Passes: I ❑ 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, ea th, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The-septictank is-metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating.,that the tank is less than 20 years old is available. [I Y ❑ N ., ❑`ND (Explain b'elovu):' t z ,,.1..1! �: .!_:� ..! r.I�u�i:� .� !. , .(�� ' ...ill. •nri!.. ?,./i%..I !ti`�Il i�• ��..�. .._ • -\ t �U 3 n�j' `aSw rs .:3:i: � "„-f4 :i1 . .o.4i� I.?; f.���ti• :�'. 15ins-3/113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 -Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments, , 103 Regatta Dr M t Property Address Julianna Biega Owner Owner's Name - required for every tion is Centerville Ma 02632 12/16/15 require page. City/Town State Zip Code Date of Inspection B. Certification,(cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due "`to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): �, ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): . ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND*(Explain below): ❑_ The system required pumping more than 4 times a year due to broken or-obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y. ❑ N ❑ ND (Explain below): ❑; obstruction is removed , . ❑ Y'. ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: I.. ❑ 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 1.5.303(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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of l7 Y . Commonwealth of Massachusetts ` F Title 5 official- 16,40ection Form i. •`tle�i•Yc .,. -1R.1S _,:ii Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 103 Regatta-Dr Property Address - Julianna Biega--- Owner . Owner's Name information is required for every Centerville Ma 02632 12/16/15 Ce page. Cityrown State Zip Code Date of Inspection R. Ceftificatioln (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public.health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a.private'water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform,bacteria indicates absenVand the'-presence•of ammonia nitrogen and nitrate nitrogen is equal ` ;ao'or�less than 5':ppm;�provided*at"no other failure'criteria are triggered. A copy of the analysis must be.attached to7this form. Y..A " 3: `Other: D) System Failure Criteria Applicable to All Systems: 'You must indicate"Yes" or"No" to each of the following for all inspections: -,`:�i,:i�:i'7',i�sil•r`_' "'-o�1i� , :�'i��:L;l� . al c ' u'I� Yes J No . Backup of sewage"into facility.or system component due to overloaded er ❑ "'� clogged SAS or cesspool Discharge or ponding of effluent to the surface'of the ground or surface waters ,, ;.. �•.r :,i®. ,:: 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'T below invert or available volume is less ❑ ® than '/2 day flow bins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title ,5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Vol u ntary,Assessments 4 103 Regatta Dr Property Address- Julianna Biega Owner Owner's Name information is required for every Centerville Ma 02632 12/16/15 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or. ❑ ® obstructed pipe(s). Number of times pumped: J:1 ® Any portion of the SAS, cesspool or;privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or, ',❑ ® tributary,to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ;. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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;equalAo 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.] 0 ® The system is a cesspool serving a facility with a design flow of 2000gpd-. 10,000gpd. ❑ . ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large'Systems:, To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary toga 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!watersupplywell 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. ti t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface;Sewage'DisposaI System Form -Not for Voluntary Assessments 103,Regatta-Dr._ Property Address Julianna Biega - Owner Owner's Name information is required for every Centerville' Ma 02632 12/16/15 . . page. Cityff own` _ Sfate Zip Code Date of Inspection C. Checklist Check.if the:following have been done. You must indicate"yes' or"no" as to each of the following: Yes. No ❑ . .® - Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or.as part of this inspection? ® ElWere 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'15.3.02(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of.bedrooms (actual): 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official ,Inspection Form .+ , Subsurface Sewage Disposal System Form - Not for Voluntary assessments 103 Regatta Dr Property Address - Julianna Biega Owner Owners Name information is required for every Centerville Ma 02632 12/16/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1500 gallon tank as well as a concrete Distribution box.All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several . leaching chambers and at time of inspection levels appeared to never have been at abnormal levels Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? (Include laundry'system inspection information in this report.) ❑ Yes No Laundry system inspected? ® Yes ❑ No Seasonal use? t ❑ Yes ❑ No Water meter-readings, if available last 2 years usage _ 238 Gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): 'Gallons per day(gpd) Basis,of design flow (seats/persons/sq.ft., etc.): Grease trap present? r ��•: El Yes ❑ N' Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ 'No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection- Forrl Subsurface'Sewage Disposal System Form - Notrfor Voluntalry°A`ssessments r'"'B`"��`�T -1.03 Regatta.Dr - - - Property Address ---Julianna_Biega- - - - Owner Owner's Name information is re Centerville ` - Ma 02632 12/16/15 i�uired for every , page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below)` General Information Pumping Records: Source of information: Pumped,20.11�,_,r,; Wass stem pumped as art of the ins ection? ` ` I ' .-, y p p p p ❑"Yes E No If yes, volume pumped: - gallons _ How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ - Innovative/Alternative technology. Attach a copy of the current operation and _ _maintenance contract(to be obtained from system owner) and a copy of latest -� -- -�gxinspection of the I/A system by system operator"under contract'' ` - ❑ 'Tight tank. Attach a copy'of the DEP approval.' ' ❑ Other(describe): t5ins-3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposai System-Page 8 of 17 Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal:System,Form - Not for Vol untaryAssessments y y x 103 Regatta Dr Property Address Juliann Biega Owner Owner's Name information is required for every Centerville Ma 02632 12/16/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 15.years Were.sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 18" ' 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.,):, ,, System is vented throught the roof. Septic Tank(locate on site plan): Depth below grade: 1 ft feet. Material of construction: H concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other,(explain) 1500 gallon - If tank Is metal, list age` i•,;. fyears Is age confirmed by a Certificate of Compliance? (attach a.copy of certificate.) , ❑ Yes, ❑ No, Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Seovage Disposal System-Page 9 of 17; - z Commonwealth of Massachusetts Title- 5 Official InspectionTo' em Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 103 Regatta Dr Property Address A — -Julianna-Biega Owner Owner's Name information is required for every Centerville Ma 02632 12/16/15 page. City/Town State Zip Code Date of Inspection D. System Infolrmation (cont.) Septic Tank(cont.) . . 11 Distance from top of sludge to bottom of outlet tee or,baffle .24 Scum thickness. 3 Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as,related to outlet invert, evidence of leakage, etc.): No-evidence of Ieakinq,Tees-and or baffles in place at time'of inspection. i-r;:r= ;ovloc7 i i Grease Trap-(locate on site plan): NA 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 i k Date of last pumping: Date t5ins•3/13 v Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ct, 103 Regatta Dr Property Address Julianna Biega Owner Owner's Name information is required for every Centerville Ma 02632 12/16/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight'or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material.of construction:, El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons - Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches,etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 =offida'F nspection Form I ..., } -..!' ry ,.. -t.ir+'f° - .•, r 4 v�a ,"a Subsurfacr*nee-Sewage-� .Dis.1posal System Form`- Not'fof Voluntary Assessments 103 Regatta Dr Property Address Julianna Biega - Owner Owner's Name information ie required for every Centerville I Ma 02632 12/16/15 page. Cityrown State Zip Code Date of Inspection D. System Information (coat.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At normal level 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 is level and at normal level with no signs of carry over or decay. 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 conditionalpass. ., - -----Soil"Absorption System (SAS) (locate on site plan, excavation not required): '-1f-SAS not located, explain why: l5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official-; Inspection Form w Subsurface Sewage Disposal System Form - Not,for Voluntary Assessments-;,;-,,r., M 103 Regatta Dr Property Address - Julianna Biega Owner Owner's Name information is required for every Centerville Ma 02632 12/16/15 page. Cityrrown State 4ip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ®. leaching chambers number. s 3 ❑ �° leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure; level of ponding, damp soil, condition of vegetation, etc.): ... No signs of carry over and no signs of hydraulic failure. 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 in ❑ Yes. ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official, Inspection Forin Subsurface Sewage-Disposal System Form - Not for Vo Ion tary`Ass'essments 103 Regatta Dr Property Address a Julianna Bie . 9 Owner Owner's Name information is required for every Centerville Ma 02632 12/16/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydraulic failure. Privy(locate on site plan): Materials of construction: Dimensions Depth of Solids-.,.,c Comments.(note condition of soil, signs of hydraulic failure,level_of ponding,-;condition of vegetation, etc.): t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 .0fficial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- 103 Regatta Dr Property Address Julianna Biega Owner Owner's Name information is required for every Centerville Ma 02632 12/16/15 page. City/Town State Zip Code Date of Inspection ®. System Information (cont.) Site Exam: Check Slope ® Surface water ❑ Check cellar Shallow wells Estimated depth to high ground water: 10+ ft feet s 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: 4/13/98 Date Observe&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: Test hole data on.plan dated 4/13/98 Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 16 of 17 Commonweal th of Mas sachusetts Titley fs, O;�ffic,ial Inspection Fo Ym�`.•. f.a�.t..i - YSubsurface Sewage Disposal System Form - Not for Voluntary Assessments . M 103 Regatta.Dr> JProperty Address Julianna Bie a - - Owner ` " "—"Owner's Name information is required for every Centerville Ma 02632 12/16/15 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 public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 .....►w aaa.v a'r►a.aa.a a a. �ty�c� ! l L./t/7'MC_ a (size) O(/) NO.OF BEDROOMS_ BUILDER OR OWNER `PERIvIITDATE: y" �" -COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leacfung'Facil ty`i_ r� - %"Feet Private Water Supply Well and Leaching Facility on site or within 2W feet of leaching facility) ' F { '"' ' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac 'ng facie ) ` Feet Furnished by .e100 29.. 23 57 i 1 FAM IL.f BF�RLL'LV� Ljt-_-E PLA til- of J B AG4 f 1F1z F as �a�aL� c�t�:rv�.. 'PAIL �"✓ ' 3 x 110 =h30 P�a�ti sync TAMi'L (J I�jOO GAL. L AGt}IiJG 5`(ST �K �ES�31 O(ZuZk)lvA(_Evi Ly"EE3 CULTsc �s3oc n sf4srouE Ttsr. — &FyUC-AMON AAA SF 2S APPL1GbTvN A¢FA �1:51bN PLAN V►tsu/ UEA541W�, .,::-�PAM8Ev-5 Sit wau Aa---11=3-! xSx2-1116 SF 13oTToAi _ iC V2- = 7arAf- AaA- s Qd�S� Frurs�l bza , i PE2ZOL,LTla*4 V47E k ''Is-YZ ZOIL Ci1t� I H OF."-,j,�s :47. d �'p . 0 J r•� e�I yi7uglE S+ErHEN S J 330 n 9 �- N Lt i , No.3J216 di !r 12 C7 055-SCEP0►4 o 1= U-75s Low sc 4v t►.�c i �`, Lsdul CHAMP R5 �a �z � �5,9 GS,b t�.tb �- s �r % ly- y �t"12C, 5:4s� G�S7atJE&!SE. ' T7►►�` /a 7 S4 u? S7DAlE B4S& pitOFlt?E- � . F,IJE �' CE"RGD PLOT do ►A-Tz�_ AT IC 1 13 5 : TKAT 't*1 E �w c-t c;,a SE�ou/N CPLAIJ CQ4tR-`�5 w.IT;1 TA lmG SIDEUN Q jai l - SDS PCo. '1 1;0gI 4 2EOu12G►GT DT= 'T116 -wvjtJ of MAF- 252 Ii� --'9AQA A— I S ilDT'LG>,ATjD W I T-4 t N A 5p�u4L ,,=Lti7D' H/lZ1�Y.b ZONE. BAXT�- � t-lYM LNG - LAuD SU¢vsYcsr-S -�1�tN�S 4- I3-99 o5ev1LL `S• :VV..OAA '5vtL.0106-5 NoT 8 QPPL1G4NT: (Yil•D TU El�T7A1SUS►� PRD'�Ty LrtJe�S. � SfDE�t,'lt_T�IiJL � ��- •.: SH�E7 2 o f Z [3.�stda Q� w,--t Ge 1= 40' Z6�►Ifr RF - Opaw SPact Si tb Opry P4cdr 64. - 62 �.•T 41 7a. 1 G,1j, 68 TN Z T 34 74 -74 7G -- 78 . Drp,� 490 10 ytr °4 'ff -99 . 92os� j�TOWN 'OFF�BARNSTABLE ©� LOCATION� 14�'7� ,Z SEWAGE # VILLAGE -�' �L 9-Aye`-XrSSESSOR'S MAP LOT- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACELITY: (type C-9A-M (size) X 2✓ NO.OFJBEDROOMS n BUILDER OR OWNER PERMTTDATE: 4/—'G- L rIE-.—COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac 'ng facili ) Feet Furnished by 1 O O a ` k F 4'. 1 �.E'J L"A- 10 Leo �\ �� CA No. 923 r Fee �y�0 r- �'� THE COMMONWEALTH OF MASSACHUSETTS 'Erttered,ipcomputer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Di-4pozat *p6tem Cottgtruction Permit Application for a Permit to Construct(L,, Repair( )Upgrade( )Abandon( ) Ef Complete System ❑Individual Components Location Address or Lot No. D 3 ie (p'/97�� �� Owner's Name,Address and Tel.No. 7 Z l Q VG Assessor's Map/Parcel 9 / Installer's Name,Address,and Tel.No. t1�ld 3M 5" Designer's Name,Address and Tel.No. ZIA 7 Job b(G14A10 6 �s�4xr�,� vVE Type of Building: Dwelling No.of Bedrooms 3 Lot Size 15. '?/d sq.ft. Garbage Grinder(Vo Other Type of Building 11100P rA-4AX No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 6 6. o gallons per day. Calculated daily flow 6 gallons. Plan Date S"ao '—Q y Number of sheets 2 Revision Date —� Title Size of Septic Tank Type of S.A.S. L i5/K_ 1V G r/9L/� Description of Soil S P e�tz_ eLqAJ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmenta Code and not to place the system in operation until a Certifi- cate of Compliance has been' e �thi�ardHealth / Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 2 Date Issued T5- T I No. "ip Fee _ !Ater-ed computer: THE COMMONWEALTH OF MASSACHUSETTS '�com s . Yes ° - u PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS. ZippYtcation for Mioogar *p.5tem Construction Permit Application for a Permit to Construct(V/ Repair( )Upgrade( )Abandon( ) YComplete System E Individual Components Location Address or Lot No.* /0 3 ie66i971A *DA, Owner's Name,Address and Tel.No. 77/w�0 y/'1 N y,g1.,v1<, bA Y5 /pi� 31 b6 CJ Assessor's Map/Parcel dZ Installer's Name,Address,and Tel.No. K c' Designer's Name,Address and Tel.No. LIa V,._ q fW, Type ofSBuilding: _ Dwelling No.of Bedrooms 3 Lot Size /5, 9/ sq.ft. Garbage Grinder(Ala Other Type of Building WOOF F/2f1/4i—c No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 66 U gallons per day. Calculated daily flow 336 gallons. Plan Date 0 `9 y Number of sheets j, Revision Date Title `- Size of Septic Tank l /17/ Type of S.A.S. L 1EF,16//1 V 6 I 6Z d r Description of Soil A S P i✓/Z PZ r9,^-/ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment Code and not to place the system in operation until a Certifi- cate of Compliance has been ' ue thin oard of Health / Signed Date Application Approved by Date 4 Application Disapproved for the following reasons Permit No. 5F Z Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (tompriance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired( )Upgraded( ) Abandoned( )by J 0i� b l /A AV at /d 3 R—EC li77'A DO. )4 MA wl� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.99' a Z dated �met Installer '*jQ /V/���� Designer The issuance o this permit shall not be construed as a guarantee that the essysta ill function as designneed. Date °' `..�' ,lam Inspec otrr➢ e� V �-� No. Z--------------------------Fee 1 (�.� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Miq;pogal *pttem Congtruction Permit Permission is hereby granted to Construct(VI)-Repair( )Upgrade( )Abandon( ) System located at /0 3 12.F G/977 4 7I/2�Y A11-115 ti and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to t.. comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t s hermit. Date:�""' �'�� ,7 Approved by �/ � �-SI� DATA r l t-1C�E FAM 1U{ �' QE�Rct�K r E pt-&ti! oh! BAGS. ram a o l-A0UA4,-- !,¢ta t�tom. ->7AI�� tawP�a� �i 2��� SSG TAN uZ I C200 6AL. 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S DE��'t�'r�tt�L � ��- TU � 1 SHOT 2 o f Z B.3:,C16 C3„,►4,.%z CA. ►= 40' ZaatF: RF - Opa., SPaC4. Scfbac►ts� 3d'/gyp�IO' 64 lot �-a r 41 70. s � 4 TH; �- 72 _ —74 _78 C*W ao 49 TT� ^ �41IV 1,3 4 92cs/ TOWN OF BARNSTABLE LOCATION a�e7—r H 1)e!1'e SEWAGE # '5-6 -2, VILLAGE Cle mrf ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �� Lv - 45 SEPTIC TANK CAPACITY LEACHING FACILITY: (type?, G 1A-M�� _ (size) / NO.OF BEDROOMS r� BUILDER OR OWNER PERMUDATE: `f'' G" L �_COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ng facility) Feet Furnished by c g h �T � 0