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HomeMy WebLinkAbout0248 TOBEY WAY - Health 248 Tobey Way 249=244: West`Hyan.4isport , { Commonwealth of Massachusetts CK'/ 7 Title 5 Official Inspe cAlon Subsurface Sewage Disposal Syf;&m Form foci* for Vo!untaN Ass zt,;,ments r= Property Address 4le-Ile oAf ner aN ner's Name n / � inforirnation is required forevery ��'!�� page. Cdylrown �L m Stag: Zip Cade Date of I n SXt 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. `Umgoutforrns " A. General Information Bing out forms on the computer, use only thetab 1. Inspector key to move you cursor-do not use the return Kla me of Inspector 14-10, Z V-10 - 7-EC 4 Compaq Nam Company Address�Gr J 15; aylroyvn Sg C)go _ / O State � Zip Code Telephone tuber License 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 16.340 of Title 5(310 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector'f 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 ciescribes 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. t5ns•3!13 Title5 Official Inspection FamSubsi face SewageDiSpWalSPISm•Page 1of17 • 1 Commonwealth of Massachusetts irTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a `19 l o6P c✓� _ Property Address ,�l/e ve to Owner Cw ner's Name i information is required for every v1✓ IS page. atyfrown State Zip Code Date of ftpedtlori B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) ='und any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 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 creed 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 e,ywain. 1. 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 tflat the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): i. t5ns. 3 Title5officialInspectlonForm Subsarfem-Sewage Disposal System•Pago2of17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form 4 Not for Voluntary Assessments � Ye %ob2 a �. Property Address T ner Osner's Name inf required Me. Clyrrown State Zip Code Date df Inspect in B. Certification (cost.) ❑ 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 Mrs•3M3 Title 5 officfai impecdcn Form Subsuf m SevMe Disposd SyMm•Page UM 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _Tobe L/4 Property Address OW ner / V etl l owner's Name information is required for every Ll a✓{h t S a/ page. City/Town State Z' Code Date of s n � tto B. Certification (cord.) Z 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 1,00 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 ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ �- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ©/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6°below invert or available!volume is less day flow than'/ f5ns-3M 3 Tile 50F5dal I speotim Form SuDsuface Savage D+sposa System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments Z�_ V_ 7o be c,✓C' Roperty Address >°vet't0 Owner s -- ON pees Narre rreequ'vredforevery /4 ✓iyU. / "-I od(70/ // /7 /�01a page. CQy/rown OLState Zip Code —D—ate—ofIns tion B. Certification (corn.) 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 yell. ❑ Li7 Y portion portion of a cesspool or privy is within 50 feet of a private water supply well. El Any of a cesspool or privy is less than 100 fleet but greater than 50 fc*t from a private water supply well with no acceptable water quality analysis. [phis system passes if the well water analysis, performed at a D®P certified laboratory,for fecal coliform bacteria indicates absent and 13te 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. 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. t5rs•3M 3 Titie 5 Official Uspectim For[Supmlam Sewage Disposal Sytem•Page S of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address �n� e to �o Ominf ere�n is Ow nees Name 7 — — requiiredforevery Lcj✓'4i1 /�i� ad-(,0/ !T page. �Yown State Z' Code Gate ofP� Zip s fbn C. Checklist Check if the following have been done. You must indicate'yes"or"no'as to each of the following: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous MO weeks? ❑ -14 s the system received nominal 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 WA) Was the facility or dwelling inspected for signs of sewage back up'? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)prwided 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 (f 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: 2 Number of bedrooms (design): Number of bedrooms (actual): — 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): — I tyns.Wry3 Tids50fficig Inspec6mFmrt SubsLrfwe Soxa9eDisposal system-Page6of17 &\ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Canf ner V o information is Owner's Name �� /� /� / required for every C7✓i c�1!t �a 6 0 ,��� page. C ity/rown State Zip Code Date of Idspeaffin D. System Information Description: / /COO 6-G /0 S 11,4to 17 /DSO �lU(i✓ /i '/u Number of current residents: ,_.,� Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection ❑I Yes B--No information in this report.) Laundry system inspected? CI Yes ( KNo Seasonal use? ❑ Yes M- No Water meter readings, if available(last 2 years usage(gpd)): o Detail: Sump pump? ❑ Yes E No Last date of occupancy: bite Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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 El No Water meter readings, if available: t9m-3H 3 Tive s officid Inspenfim F om[Substrfaoe EevMe Diepaal System•Fnge 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • j T f -- Property Address Ow ner Ow pees Nameinforrnation is / A required for every /?�e;0 14 page. Cityyf row n State Zip Code We of lns0ec4W011 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 If yes, vol umepumped: 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(descri be): tons-3H3 Me5offidal inspeetienForm Suburfam Sewage0ispos9 SWMM•P39e 8017 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1(g T O L-e _ Property Address ,{� ONner O /� eve o information is wner's Name required for every a dI vi tl page. Cthf/rown State Zip Code Date of spec" n e D. System Information (corn.) Approximate age of all components, date inst e d cif known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): 6 // Depth below grade: feet Material of constructi;%40 ❑ cast iron 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 /0 �— Mate! f construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearn Is age confirmed by.a Certificate of Compliance? (attach a copy of certificate) CI Yes ❑ No Dimensions: Sludge depth: t5ns-W3 Tius5offieialInspectenForm SutseaceSexcgeDispmd System-Page 9of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �R Property Address o 6to�/ / Owner ✓�' inform t ri is OH Hers tVarrfe / required for every Ci P14ej Da 6,� / 0' 11,6 page. Cdy/rown State Zip Code Date of Ins tin D. System Information (coat.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle / r1 Scum thickness Distance from top of scum to top of outlet tee or baffle -- �r Distance from bottom of scum to bottom of outlet tee or baffle -- How were dimensions determined? V- le /�G Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PC'4' �''� I t7 ;4o G vt �.. a of cJ 7'P�_S' l r/f COvt N/�lQ✓1 i 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: We - tans-3H3 Title50ffidal InspecfionFom SubsurfawSevggeDispossl System-Page 10of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form /-Not for Voluntary Assessments c) VO l 6✓-e �a Property Address L,7 6� Ow ner Ow ner's Name information quinto is v 6O l %,6 required for every q rtr�r j page. Cilylrown State Zip Code Date of Ihspeefion D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, e%idence 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: gamin Design Flow. '— gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng order: ❑ Yes ❑ No Date of last pumping: Date — Comments (condition of alarm and float switches, etc.): f Attacti copy of current pumping contract(requires!). Is copy attached? ❑ Yes ❑ No 15m-3f13 Tiue5official i spectianFomc Subsurface Sewage Disposal Swam-Page 11 err 17 f' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ke /Ohrrt er (�e 1oj 6; information is miners Name l required for every / G1✓l�lf / ' �o�6 11, 102 page. CiyRown State Zip Code Date of Ins tron D. Syste nformation (cont.) Distribution Box (f present must be opened) (locate on site plan): — Depth of liquid level above outlet invert Comments (note(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: tsars.3(13 Twesomcial IrspecunForm Subwface sswageDispmd System*Page 12 d 17 Commonwealth of Massachusetts lug Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not fior Voluntary Assessments 02 �' /o 4.e Roperty Address /�/ .— ow ner / �ve infom&n is ON ner s;Name _ 1 requiredforevery q d1 P1 If /�/1 �d 60 page. Cdy/Town State Zip Code Date Inspection D. System nformation (cont.) Type: /- %OW ❑ leaching pits number. ----- ❑ leaching chambers number. — — ❑ leaching galleries number — — ❑ leaching trenches number, length: — — ❑ leaching fields number, dimensions: — — ❑ overflow cesspool number. — — ❑ innovative/altemative system Type/name of technology: --- Comments (note condition of soil, signs of hydraulic failure, level of ponding, clamp soil, condition of vegetation, etc.): '5PNC� v�J� 1 �'cG�l :�70 , S� �s o7" CJ c /ir 7< AID. 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 ❑1 No t5ns•3M3 riile6Official Inspeclion F am Subsurface Sewage Disposal System•Page 13 cf 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form of for Voluntary Assessments property Address aIr ner ON ON ne nration is r's Name required for every _ cir/Idl/1 /�/� 00601 /4n!p/e;WZn page• cKy/Town - Zq�Code /D. System information (coat.) State Date of 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, t5ins•3113 TitleSOffiaal IrspecknFans subsurface sewageDispasal System-Page 14 d 17 s e Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -//Not for Voluntary Assessments Property Address Om ner Oer ner's Name information is required for every page. City/Town State Zip Code Date of oispection D. System Information (cont.) Sketch Of Sewage sposai System: Provide a view of the sewage disposal system, including ties to at least two anent reference landmarks or benchmarks. Locate all wells Wthin 101)feet. Locale where is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately n GArc,7� �o�w � ev- 3 / Q s ;V►v t9ns•W3 TiteMfidal I specfianFam Subsurface Sevage0isposd System,Page 15 cd 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments io- Property Address — Ow Ref ON fter's Name information is 1, n -- required for every page. City1rown State Zip Code Date o 4�spec' n — D. System nformation (cost.) — Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / It'40 to f— 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 ❑ served 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 desc' how you established the high ground water elevation: / �^ 0 fit �'JG✓l d Ct Lt ✓ /�' l � / �/ vv� lz9l a�j s WO t1t- _. �o 1A✓d Before filing this ln*ection Report, please see Report Completeness Checklist on next payee. t&ns-W13 Titie 5 official Inspection F orm Subwam sewage Disposal System•Page 16,017 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Om irifa is Owner's Nam requhWforevery / 40 4 Pap. Oyfrown Stage Zip Code Dateuf peebon E. Report Completeness Checklist t_7 Inspection Summary:A, B, C, D, or E checked "pection Summary D(System Failure Criteria Applicable to All Systems)completed 2�Sketch Information—Estimated depth to high groundwater of Sewage Disposal System ether drawn on page 15 or attached in separ<rte file r Am,3h3 Tae5of6 W JWp8C3MFa=SUDsOMB ShIVODispasd sysbm•Page 47 d 17 '� ,� �� �� �, ;' �1 ��4 _ 4 V ;` t ' i r t,. Commonwealth of Massachusetts Title 5 Official: Inspection .Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 248 Tobey Way Property Address: Belisle - Owner Owner's Name information is required for —Wem+tyarTRfsport �Ia �{n S MA_ 02672 November 15, 2010. . _. ... - every page. City/Town — State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the �'•- _ I_�11 r computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 "A7 City/Town State Zip Code 508.428.1779 SI 12855 Telephone Number Llcense,Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the informatiori 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 i Title 5 (310 CMR 15.000). The system: ° r � ® Passes ❑ Conditionally Passes ❑ Falls =-y Needs Further Evaluation by the Loc9l!Approving Aiatiority � r, V L11 v " November 15, 2010 Job# 10-276_ Ins ector's Signature Date 011 rn 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. �v l5ins•09108 I I v Title 5 Official Inspection Form:Subsurface Sewage Dispoll ystem•Page 1 of 17 Commonwealth of Massa chusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 248 Tobey Way Property Address Belisle Owner Owner's Name information is West H annis required for Y port MA 02672 November 15, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CIVIR 15.303 or in 310 CMR 15.304 aids#: Any failure criteria riot evaluated are indicated below. Comments: Tank in need of pumping at this time leaching system showed no signs of saturation or surcharge. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced wiih 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•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for _West Hyannisport MA 02672 November 15, 2010 every page. Cityrrown State Zip Code Date of Inspection 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. Ctty/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 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 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_day flow tsns•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachu setts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 every page. city/Town - November 15, 2010 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. 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. t5ins•09/08 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 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. Cltyrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 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 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. Clty/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessment s 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank last pumped 12/13/08 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Comliance date: 1/18/96 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1' 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: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage System Disposal S p y m Form Not for Voluntary Assessments M 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 every page. City/Town - November 15, 2010 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 28 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Baffles were intact and clear, liquid level was found at bottom of outlet invert. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass 9 ❑ 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•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `M 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. Cltyrrown - 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 9 El 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 248 Tobe Way Y Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 every page. City/Town November 15, 2010 State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): No solids or high stains present liquid level wa's found at bottom of outlet pipes 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Three flowdifussors. ❑ 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.): . Area of SAS was probed with no signs of saturation found. Leaching system shows 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 inflow ❑ Yes ❑ No t5ins•09/08 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 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not foro VoluntaryAssessments ments 248 Tobey Way Property Address -------—— —— ------- Owner Belisle information is --"-- _---------------------...--------"---- Owner's Name required for West Hyannisport MA__ 02672 every page. City/Town State Zip Code November 15, 2010 D. System Information (cont.) P Date of Inspection 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 F-1 drawino attached separately ! r / r ! r r r'r ! ! / / r / ! / ! / / / / / ! / /`/`!`!`! ! ! r / ! / ! !./ ! ! ! / ! / / / / / ! ! ! / / / \ \ \ , t \ 40 /NNN 3 r ! r r / r r fN N % r ! , , \ , \N , N" , r , , / `/`/`/•/`/`r`/`/`/`/`/`/`/`/`,`/`,`/ r r / r / / / / 15 Toibey Way Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 248 Tobey Way Property Address Belisle Owner Owner's Name information is West H required for yannisport MA 02672 November 15, 2010 every 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: 10 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Low area at rear of property with no surface water is considerably lower than bottom of SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 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 248 Tobey Way Property Address Belisle Owner Owner's Name information is required for West Hyannisport MA 02672 November 15, 2010 every page. Cltyfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 to-�eTOI B"ARNSTABLE LOCATION SEWAGE# "' VILLAGE, W ASSESSOR'S MAP &LOTS e('7-F INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IX)o LEACHING FACILITY: (type) 'N Gam+✓ y i f o S (size) `lk P NO:OF BEDROOMS BUILDER OR-OWNER PERMITDATE: J� /� , ``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 leaching facility) Feet Furnished by j� W V,3jo � N i- r, w N t J No. -•.7 - 1 ASSESSORS MAP No PARCaNO Fee AVM THE COMMONWEALTH OF M PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[pplication for Migaal *raem Construction Permit Application is hereby made for a Permit to Construct(X)or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Q �wn'e�r s Name Address and Tel.No. i.g,T ,i Tt>z&Y W AkeI�0 kX H Y.��nra S p r►� �� ti lei !� 0 Installer's Name,Address,pmd Tel.No. Designer's Name,Address and Tel.No. 44 $ � 1 E#'2 A-A-1 iv 15 7 7 iB—-4 c4 T7_ Type of Building: Dwelling No. of Bedrooms 3 Garbage Grinder(Po Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 33f3 gallons. Plan Date I 1,& Number of sheets i Revision Date Title 5P,57& 7�S���u -v� ��xY C"-A, Description of Soil ZY 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo f th. Signed Date I 7,4g Application Approved by =Application Disapproved for the following reasons Permit No. Date Issued ��' r w.... l ,.'» {pry -J.c' • k .' Y. . :f.S-Y C- r i.wT 1 W pY�Y c �•49� R.. / Fee X �= THE COMMONWEALTH OF MAS6A61USETTS PUBLIC HEALTH DIVISION TOWN OF BARNSTABLES MASSACHUSETTS i s 01ppricat on'.for Migogar *p5tem Cougtruction Perron _ Application is hereby i ade4or a Permit.fo Construct A)or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. ' V iOwner's Name Address and Tel.No. 1•oT 9 -To-Nf- w Y / v Ilia woo—5 r w. N YA-&)N i S Poy—r *1b 'd f- Installer's Name,Address,pnd Tel.No. Designer's Name,Address and Tel.No. t o se--4,S o MW NJ. t4-e A-0- g 7?e—,}q 7-z Type of Building: Dwelling No. of Bedrooms 3 Garbage Grinder(PO) 4 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 2 Design Flow J3U gallons per day. Calculated daily flow 33!�) gallons. Plan Date // �� 41+ Number of sheets Revision Date TitleE-, aZe Sf�57�'+`'r 7.1er�/Sti Fae f-t�9r�.0 ryzso �, Description of Soil H e=:0 J4 G N 8�� Nature'of Repairs or Alterations(Answer when applicable) { Date last inspected:`{r . Agreement: - a f v The unde signed agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been itssued by_this Board f �Ith. Signedt Date I Application Approved b / Application Disapproved for the following reasons Permit No. Date Issued � s THE COMMONWEALTH OF MASSACHUSETTS 4.• ,P,UBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance_ T IS IS TO CE F�FYag;-,On-site Sewage Dis osal System installed(� )or repaired/re paced( )onby /�� LfJ�1� for 4 ` as has been constructCd to acco dance with the provisions of Title 5 and the for Disposal System Construction Permit No.9 Cr dated Use of this system is conditioned on compliance with the provisions set forth below: 1j , r No. -i�'" F/ Feed THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS ligpotar *pgtem Construction Permit Permission is hereby granted to to construct Vrepair( )an On-site Sewage System located at [� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions.or special conditions. All construction must be completed within years of the date below. Date: : Approved b4� jF(E t 1-1 ; 0 rnr, r,,�m 7 7r 3717, 777! AN 77, '7 4A, R v VA,,T, �O Ns .-GN CR TERJ A ACCESS COVERS MUS T BE WITHIN �At ��'JNYER T-, NERA L­­� 0 TES, ELE DES )t INVE N/SH GRADE OF F1 LOW RT, AT',gUILDIW4 DES I aN;F� THIS -PLAN"IS FOR THE DESIGN AND� A T / /0 G- 'INVER T Iff'SEPTIClANKi L'.,,32_. 0L EDROOM'S P :PER , 35.00 -1-B ;CON$TRUCTION�OF THE' sFWAGED1$POSAL FIRST 2*: TO BEDROOM EQUA S 3JO G. P. D. , :BE LE �:32AO T OUT �SEP Tl C NK. VEL' JNVER TA L '$�$TE �O L Y.� 4­�PVC_ 'DIST. BOX.- 30' - IN.' 2' OF INVERT , 1N. ALL, CONSTRUCTIONME U 2, THODS AND, MA TER IALS PEA S TONE 2i 0 'HE SEPTIC SWEY 32,JQ NO. :GARBAGE GRIINDER AWMAINTEIVANCE: SCHED E 40 INVERT,,,,,,,'OUT DIST. �BOX: , 0 I N VER T I N -L EA CH Cht�MB&�, [-�96 ALL")CONFORM TO MASS D.E' P,,jI LE-5 W12. , .514 1 112 DIA. AND �i OC L ,'BOARD OF, HEALTH �REGULATION ' 3-4'X 8 A rl�WD I FFUSORS SEPTI' C., TANK REWIRED:, WASHED STONE -LEACH CHA MBER 30' 90 ' WONE AROUND. 6-X 28- BOTTOM OF G P OVERALL 4 GAL,� __L OUTLET ;­ ..... .. 95, 330 D. _,,Xl 15OX OF IN. 1 1000 1,6..go GAL -BOX 'A DJUS TED GROUND WA TER GAL . ' A L SEP I C 4 YSTEk-COMPONENTS LOCATED L T LIMI.-T -- "TION /000 SEPTIC TANK PROVIDED N0'kR,AREAS,..SU9JECT�T0 VEHICULAR TRAFF1 V90ETA C SEPTIC TANK' 7� -50 OBSERVED GROUND WA 7 IN DEPTH SHALL, BE 14.6 GREA TER THAN' 3 ��OF LEA CH I NG FACIL I TY REQUIRED: A -0. 70 CAPABLE OF W1 HS BOTTOM V; TES T HOL E. SIZE 'rAND I NO,9-20 WHEEL LOADS. FROF1 LE -* NOT TO SCALE 'G. P IND 330 EX WEL L M W 2 ZONE D. '4. ALL SEWER PIPE',SHALL BE $ChED CIL E 40 DESIGN PERC RATE 2 "M I N/I NCH -4195, READ ING-9. 0. 4. 4 ADJUSTMENT OR'APPROVEL)�,EQUAL, 6 ED 3-4 'X -8 FL6WDIFFUSORS W12".� �PROVID ON'STkUCT1,ON CALL �5, BEFORE C 26 ' OVERA L 4844 AND HE, LOCAL WATER DEPT. STONE AROUNDL, 8 'X 2- W 2.:5,L"' FOR LOCATION-OF-UNDEROROUND UTtLJ TIES. , �SIDE ALL , 7-. F.X 2,�4 S. FOX 1. 6 0 : , , BOTT ' 224 GpD, , ASSUMED '­6." VERTICAL,'DATUM IS. 296 % +,17.9 404 TO TAL S.F. 7 R,�B E S FO ENCH MARKS SET. S E ITE PLAN. S.' "W'DETERMfk�TION NA 5 BEEN MADE"AS -TO W T CrIOkS OR TES, T PL/ T D ' COMPL ANCE W I tH,DEEP:RES TR I N 8 '09 1 1 S 01 L,�' A 167., +26.4 REMA IN ZON I NG EaULA TONS T SHALL THE 'C�l,'&TS CA PON$ I ES I B I LI TY TO OBTAIN PERCOLA-TION OBSERVED GR 0 UjVD#ArER "PEOW I SPECIAL PERMITS �*ARIANCES AL to.5 r ',ETC.' FOR,�TH 'S PROJECT", Tp LOT 9 y IT SHALL,;- EMA IN f8t,Ct I ENT $ RE$PON$I B I L I T i4.6 32.7 + To HA 12.VLOT I I ',aUILD' I NG FOUNDATION , _150" 68 G.W.EL'. S T ING GRADE, DES I G TO A 66OUN,T,FOR tl4k-&t 0' .7 :"�'AND SO/ -C60171­&S�AT THE OCA r I ON OF,'THE 32.55 'iROPOS`ED. BU?L D I NG. BOTTLES TOPSOIL +t7.4 $ '10. C rEM D rp,Tl YS CE SUBSOIL TH!S ESIGNED IN ACCORDAN EM 10 WITW�10 CkR: WAS - ING BOARD ON.AUGUST.'8. 1-0 4 ENDORSED BY�:THE'�PLANN +17.2 28.7 +29.?v Ubf MED I 4" SAND. ? I I VN�Ul rA, TERIAL (TOPSOIL, SUBSOIL, 32 7 ETC FiLC E)VICOVN TERED'BEL 0 W THE 'INVERT I OT. 9, S GRA YEL _2641+ 24.' F 7* OF THE LEACH PIT TO:BE.lEMOVED'FOR A D IS TANCE�,OF 10 AROUND' rl HE"P I T, DOWN TO j THE i�L E0 IA AfD 4A Y k�A D' RtPLACED W1 dEAN MED I UM SAND, + MED I UM SAND < R k 7 + TER 7 2 5. ;%l 'DA TE: APRIL , 18.: 1995 T 09 A 10,3 S TEPHEN HAA S TES T B y. WNESSED B Y:. -BARR Y ED T" kINIINCH, - PERC .RA E" _2 5. 10, S T EV 12 + ,5�1 g '21 e 7, J.1 W ),�A�Nl\l S P 0 T '"A flu. +Z71 4 ARA R 5 '432.3 �4 ::4ac.Tv R'R E-P A R E-D OR p 4010IFFUS OR$ 32.54 �7 1#0 6,4L ir/2 $TOME RO&M A 44 MP T1 C tANK 14 30 N 0�VE7"d9'F p J `45 �EE WE 1 9 5 0, -sox s cA L E 20 rr"T'l v 11v 0, V�T 2 s TO T 37 , 7 �E ��Z/R "M '0 LOT , �A 13 5.2 J,1" I vi, 4 2" & 43 LVO oy 10 `7� % _77 7m!� ,�67.76 2"� "0 .20 �i� j O�, H CFO q: 41 'n 8 P 19 R _SA 0 i'L;'?� 240�, F I ��-`__Wfrpj T' "j i�s 'A-4;VL 5� "T V ­n;- J­ & tz -y kf, g t 7' 7" �7 `e: 7 7 7-777777777 EL EVA T 1_ONS ER [A- N VER ERA L , : NO TES ACCESS COVERS MUST BE WITHIN IP* :OF FINISH � 'JNVERT AT BUILDING 33, 15 %FL OW: _GRADE DES GN rH/ PLAN IS FOR THE DES I ON AND 35.00 CONSTRUCTION F'1HE�SRA6E DISPOSAL INVERT IN SEPTIC TANK. 32. 65 3 8 ROOM$ AT 110 G. P'. D. PEP FIRST 2 TO '32,�10 BEDROOM EO OALS -330 G. P. D. INVERT. OUT SEPTIC TANK. �iStr,� ONLY.' BE LEVEL MIN. J2, JQ 2* OF JNVERT IN DIST BOX, 4',-PVC TRUCTION' kE-THODS'AND, MATeRIALS. �SCHEDULE 0, PEA$TONE INVERT:OU'T DIST, B ,THE sEprirc-Sysmm OX: �2, 0 AND MA INTENA� NCE OF" Ol 'SHALL:�CMFORM TO �MA SS., D.E.P. ' TITLE 5 \,MAO 314'-'- 1, 112 DIA 3 INVERT,1NIEAcH C14AMBER: J/ .90 J-4 LowDIFFUSORS W12 .495 8'X'28 0 VERA AND LOCAL �BOARD,OF OEALTH-REGULATIONS. WASHED STONE BOTTOM OF LEACH CHAMBE)? 3_0 SEPTIC TANK REQUIRED: F� OUTLET . 90 STONE AROUD. LL 330 ,G.P.D. X� 50�e /000 GA L MIN. 6A L D-BOX� -A �compoNENrs -LOCATED r;�T-ATION TED GROUND WA TER: tL srmc�syTtk ADJUS 16. 90 SEPTIC TANK PROVIDED: 1000 GAL .' 'UNDER AREAS SUBJECT TO VtHICOLAR TRAFFIC -+Ew 6 -SEP TI C TANK 'OBSERVED, GROUND WA TER, 12,50 14.6 OR ��GREA TER THAN 3 IN DEPTH SHALL, BE 19. 70 , BOTTOM OF TEST HOLE. SIZE, OF 'LEACHING,�FACI`L I TY REQUIRED, CAPABLE oF ,W1THsrANDiNe­P-PO WHE ' LOAD . PROF IL E,: NO,T 'TO SCALE 336 , ' G. P. D. I NDEX WEL L MIW 29'. ZONE C ALL SEWER, PIPE $HALL BE,SCHEDULE 40 W NCH DES 16N PERc RA TE C2 m/ 4. 4 ' DJUSTMENT -OR APPR 0 VED EQUAL. FLOWDIFFUSORS W12 -4 *X 8 TRUCTION "CALL "D!G`­SAFE% PROVIDED: 3 ;1-80,0-322-4844 AN6�THE 'LOCACWATkR DEPT. STONE AROUND., 8 *X''28 OVERALL FOR.�L OCA T ON"OF 1 UNDERGROUND UIL TIES. S I DEWALL 72 S.F X_ 2, 5 /80 Gp BOTTOM:' .224 GPD VER ICAL'LDA S F.X rum,,Is.,�A$SUMED 17.9 TO TAL 404 296 .6PD'+I F, R BENCH'MARKS SET. SEE 5 1 TE PLAN. 7. FO 22.4 8." NO DETkRMINATION HAS BEEN MADE"AS TO + COMPL ANCE WI TH DEED RESTR CTIONS OR 81- +26.4 -T DA 'TA �'ZONI I NO REGULATI ON$.' I'T SHA LL P.EMA N SO L, TES T P 167 7�+/l THE CLIENT$ RESPON! B I L I TY, TO OBTAIN ND CA TES INDICATES PERCOLATION OBSERVED AL L�� PERMI TS., :SPECIAL. .PERMI S. ARIANC $ TEST , GROUNDWATER ETC." FOR THIS PROJECT. TP LOT 9 EMA IN 7HE CL,I ENT RESPONSIBILITY + 0 6 '9,.; 1 T,SHALL 81 GRND.EL. 32. HA VE TO ThE,,'PROPOSED 0U1,LDiNGF6UNDA TION G. EL, 12.S(LOT 11) �DrSIGNtD:l TO'A' C`6OUNT.FOR THE'EXISTIWORADE 10 AND SOIL, -HE COND TI ONS� A T, THE L OCA T I ON'OF 7 .7 PROPOSED BUILDING. 2.7 BOTTLES +17.4 TOPSOIL _40, THIS SEPTIC SYSTEM DESIGNED 'IN ACCORDANCE SUBSOIL W/rH 5.-� 5) �,THE,SUBDIVISON WA N 110,CYR rHE 'PLANN1A($ BOARD AUGUST4. i4.9 'ENDoRsED BY ON 4' 28.7 $AND VNSO/TABLE MATERIAL (TOPSOIL.�'$UBSO IL' -9 MEDIUM +2 &OU1,VTEREV BEL'OW', THE 'INVERT' 2.7 F LOT 9 SOME ILL TO EN, 22.6 GRA VEL oP THE 1 EA CH,PI r,TO RE90 VED'FOR''A 24, 2644 7' 25.7 A' F,,, 0 ARO ND THE P D DIST NC OWN" TO _LAYER��AND'REPLACED Wif TH HE X LrA N SA ND CL EeN 1WFDIUAi:SAffD. MED I UM SAW .4 +30 2 7 32 NO WA TER 1+ 12 9.71 2, 18;, 1995 DA TE-: ,4PR L WAT LIN15 STEPHEN HAA S TEST By, 3.09 , 'ED W1 MESSED B Y. BARRY 15 PERC RATE: (, 2 INIINCH S YS TE O,E 15 0 _ P T IEW + '12.06 0A YA N/V SP OR T -+2714 SA R /vs TA RL E MA 32.40 R E-RA R E-D 0 R J-4!x S' FLOWDIFFUSON$;l J2.54 . 1112 SONr ANOLM wo 0 "0 C� 0 R p 1000 GAL_ SEpric T�mx 4.51 130" 2 0 D46X' NOTE fr-�, Q� 1 S C-A L E- N 0 VEme L R t9--TES tP I T RE- V S4= /\/O VE"zg E- A7 G Z.1 VO LO T :0," if e,cz c7 .2 4V 4 0 4 0 .7, + 00.. -0/ 51 0 ................ PA rftAN$F0RMEft PIR pmmq pmmmmumm 7T� :� Ck D L,C: 'R V1P R AH SAHICr CFW, 0