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HomeMy WebLinkAbout0089 WAYLAND ROAD - Health ..... . . . .. ._. ......_ 89 Wayland-Rdad Hyannis A= 271-227 ,/� �7 COMMonwealth of Massachusetts F Title 5 Officloal Inspection r Subsurface Sewage Disposal System Fo m Not for Voluntary Assessments Prope— rty Address �� �3!n / r Owner C4 ' . information is Owner's Name required for every Od- / C� p. page. City/T—own /—°� � ® � �;� State Zip Code Date of I pection 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 �o General Information on the computer, use only the tab key to move your 1 Inspector: cursor-do not use the return -a ___ / key. Name of Inspector --------- -S'� us Company Name Company Address City/Town/` / ®J 1 ) Q C` ® _ ^ yno State Zip Code I e_le_phho_ne Number J U /s` - ��� License Number - Be Certfficj�tjon 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 IR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Ne ds 7urther Evaluation by the Local Approving Authority qZ r inspector's ignalure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc•rev.6/16 Title 5 Official Inspection Fomr Subsurface Sewage Disposal System•Page 1 of 17 1 o VS Commonwealth of Massachusetts Title 5 Official Inspection a Subsurface Sewage Disposal System Form-Not Voluntaryf ®� t� Assessments �/4 A �� Propert— y d / // ] dry Owner ------__ L 14, I Ga L l information is Owner's Name required for every AAl , y�If — �� ®a page. ;B. y/To w�— v/ ------ State Zip Code Date of specti n Certsfjcalo (font.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 7te asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair; as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,' please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17 COMMonwealth of Massachusetts -tie 5 Offic-al Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M -99 G�� /a0 Property Ad —dress ner'— s N h Ll information is Ow required for every ` --flown . G 0�1 g ---6-® page. City/Town ------ State Zip Code �D�atebfpecti n a Cefifficato®n (coot.) ❑ 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 ❑ ❑ 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 16.303(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.doc•,rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 a. Commonwealth of Massachusetts Title Official Inspection rm Subsurface Sewage Disposal System Form-Not for Voluntary &-ci Propert--y Address -- yg_ Owner Owner— s Name---- /ci !� information is required for every �— page. City/Town ®�/ p — State Zip Code Date of In pec i n e Certjfjc a` flon (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 sysl;em 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 Faiilure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ L� 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 ❑ E7 Static liquid level in the distribution box above outlet invert due town overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less f _ than day flow t5ins.doc-rev.6/16 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For ° Subsurface Sewage Disposal System Form Form -Not for Voluntary Assessments. �d Property—Address Clj6 ress ------ Owner information is Owners Name required for every page. City/Town State Zip Code Date of nspectio Bo Certification (Cont.) Yes No ❑ y Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ M�— 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. ❑ Lrd' 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.] ❑ Z/"Z� 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 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 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.doc•rev.6116 Title 5.Official Inspection Form:.Subsurface Sewage Disposal System-Page 5 of 17 Coirnmos wetalth of Massachusetts Title 5 Official Inspection For a _ Subsurface Sf9wiage Disposal System Form••Not for Voluntary Assessments Property Address Owner Owner's Name � W � Pi�� information is required for every y�'f page, Citylrown �� State Zip ;Dateof � ��eCk�9S'� �Ipectio Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes �_j mping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? s 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? Cl 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. Ej 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 Ila_t®rriaa ®n 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): 3 3 C t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 C®mmonwo-alth of Massachusetts w Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name V7 information is 41 required for every q J page. Citylrown State Zip Code Date o?1pectio;n' tZ ®a System Information Description: / /00® 6,, 11 13 -�sa z"7 119 0 0_11� . 'z Number of current residents: Does residence have a garbage grinder? ❑ Yes Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes o Laundry system inspected? ZYes No Seasonaluse? ❑ No Water meter readings, if available(last 2 years usage(gpd)): — Detail: Sump pump? ❑ Yes No Last date of occupancy: C,(Avyeo Date Commercial/industrial Flow Conditions: Type of Establishment: —_ Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): -- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - ----------- — t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 Commonwealth of Massachusetts Title 5 Official inspection For a Subsurface SMage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name 4ei 1 C� information is required for every page. Q� 6 CityylTown — State Zip Code Dat of nspecti n D. System format on (coot.) Last date of occupancy/use: Date Other(describe below): General Information Dumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S em: 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.doc-rev.6/16 'ritle 5 Officiai Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 C®MM®nWealth of Massachusetts Teltle 5 Official Inspection m a Subsurface;sewlge Disposal System Form Voluntary Assessments Property Address Owner f e information is Owner's Name 4 required for every q page. City/To_ wwn e�B if D. System tate Zip Code Date of In ection � ttf®�m�ta®� (cont.) Approximate age of all components, date installed (if known)and source of information: ----- ✓ Were sewage odors detected when arriving at the site? ❑ Yes No Building:fewer(locate on site plan): Depth below grade: � ®/ fee— t —--- Material of constructi;'4-0 ❑cast iron PVC ❑ other(explain): / Distance from private water supply well or suction line: ! 2 feet Comments(on condition of joints, venting, evidence of leakage, etc.): ------- Septic Tank(locate:on site plan): Depth below grade: C)— !� • feet Material nstruction: concrete El 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 ElNo ; Dimensions: Sludge depth: 311 . t5ias.aoc-rev.6/16 —.—.------- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9'of 17 Commonwealth of Massachusetts M Title 5 official Inspection For a Subsurface St:wage Disposal Systems Form-Not for Voluntary Assessments Propert d ss Owner Owners Name V7 information is required for every page. Citylrown �State Zlp Code �Datespecti n D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3 s r/ Scum thickness i� Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 0 /-e Comments(on pumping recommendations, inlet and outlet tee or baffle liquid levels a condition, structural i q s related to outlet invert, evidence of leakage, etc.): integrity, ,7/0_ 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 bottorn of scum to bottom of outlet tee or baffle -- Date of last pumping: Date l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Co11711711n'oonwlealth of Massachusetts _ We 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;`M �✓� ��` C d rt—Prope y Address �� ,/ Owner v°� 4 �Name (2 information is Owner required for every C,a/b diJ I AIA �� l page. City/TownOr State Zip Code Date of I U. System Information (cont.) Pection 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 ❑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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 COMmonwealth of Massachusetts W Title 5 Official Inspection Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. CitylTown o r_ ec /�. ®. Stag Zip Code Date o I ho �ateM nformatson (Cont.) p 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, evidence of leakage into or out of box, etc.): any Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ Noy 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: f t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 " C®MMon%Afealth of Massachusetts Title to Official Inspection a Subsurface,sewage Disposal System Form-R!ot for Volu �r 9 Voluntary Assessments Property Address "" C,§4 C/ Owner Owners Name � 4w information is required for every _ r /,1 ®� / page• City/To / Date of ns e 6—'-"�--- State Zip Code dion System nformataon (cont.) Type: leaching pits ,S -4 a�t� 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.): � �_Vf > oz elk 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.doc•rev.6/16 'rifle 5 Official Inspection Form:Subsu face Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection' a Subsurface st;rwa a®is � � 9�{/y/(/)Disposal system Form-Not for Voluntary Assessments ' M V Property Address �C Owner Owners Name � information is required for every page. City/Town � ! �®� State Zip Code Date of ns ection ®a System Iffiformation (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.doc•rev.6116 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For _ SubsU face Sewag e Disposal System Form-Notfor Voluntary Assessments Property Address Owner information is Owners Name ` required for every G;&A�//p f ��/f� page. City/Town State Zip Code L Dat o Inspe ion Do System nformation (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 su i enters the building. Check one of the boxes below: C { o 9- d � I 3,2 o del �-le- i I dv-''S C x 6 S � t5ins.doc•rev.6116 Title 5 0fricat inspection Form:Subsurface Sewage.risposai System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Foy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - -----Address roperty- , // ✓a Owner P --a--_._— information is Owner s Name > required for every page. City/Town State Zip Code Date f Inspe do Do SYStem Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) L� Checked with local Board of Health-� explain:/ �" / &S--� Igo lec ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Sl_l/1 $-rim 46, �,� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 ®ffscial Inspecti®n Form Subsurface Sewa ge Disposal System/Form-Not for Voluntary Assessments M Pro v✓�/! l A 0 Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of I spection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed LJ 5 em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 - - 'fitie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 fi Gorrlltnonwealth of Massachusetts ` i itle 5 ` lInspect'L Subsurface Set"race Disposal System Form - Not for Voluntary Assessm.en.s v✓ �f vt -. r-ropertyAdd` a -------------------- recuir atifo is � reeuired for ��_�Gia'1`II,S_ every page. CitV,,IOW - S_ace %ip Code D_t_C,7 :,, _vo,iv---------- Inspection results mriusf.be suramited on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. 0 Important: ---- --- — �, when=i!iincou` A. General Information — f'lij� forms on the computer. use fffttt llJ if ! only the tab ke✓ inspector: //'/ ////y� /✓ `/J ova n c M. cursor-doo not -------- -- li Name of Inspector _--- ----- ------- --- use the ret N urn - I' iYYeO I key. ------ ----------------------------------Company Flame -- -- ----- �d �soX Jdcd� Company Address //------ -- ---- --------- -- ---------- r� C tvl ov,/n ---------- S — —— - —--- ---- •/�/. '/�/ /q//A' -ta.a elephcns i\'umber _•cease Nu:TSer IB.. Certification I cerlify that f;have personally inspected t e sewage disposal system at this address and `'G ne InfCi matiCn "EpOrted below is true; accurate and complete as of the time of t e finspecTion.. The InSneC:!on, was pe,~;ormed based on my training and' experience In the proper function and smaintenance CT Or', Si C selvage disposal systems I am a DEP approved system~; inspector pursuant to Section 15.340 i Titte 5 (310 C,'MR 15.000). The system: a �cndit oraliv Passes Needs Fu ti ier =valuation by the ocal A}7�'�Vli!g A, tt?CritV _0 Cal � o Incr2cto. Signature — ----- mate — —�T-- he system Inspector shall submit a copy of ti-:is nspec-Jon report to the Apc o':li-:g `c of i Health or DEP) within �0 days of completing this InS_•emion. if the system is a.S',' ed' S'f ,t .,,, Cr has a design flow of 1C,OOQ gpd of greater, the rsoector and the systern owner report to the appropriate regional U ice of,ne DEP r ne Cricinal would b-2 sea , rC .� ``/s- .nvr' t and COO,eS sent to the butler, if applicable and! t;ie approving i ori'" I ��-I i"1 -1. i 1 This reciort only describes conditions at the time of inspection and under the Conditions ci use i at that time. This •!nspecf on does not address how the system WHI performs in the future under the same or different conditions of use. I' � O I t5ins•09/03 , ,. C—i-nonweaith c f Massachusetts •P �— Fs dt Subsurface s, ✓ eac e L3is�;o=at System FormNot for Voluntary _ - _.-ice ' LA N�• Prop ert,�•Andress --- -------------- - - - Ir I' Owner O+rmers Name — - -- --------------- information is �l /� J reeul ec for --- �j nib it - - '_� �O��1JJ eve•^J Dade. Ci'`i,l C•V:n 7ii'Cod �± Inspection Sumrna:y: Check A,B,CS Eh or E/ahways corrOete all Of Section D �i is A) System Passes: e I'� have nr_)t found an inform tip h a n v C". IndiCate5 - Lan)/ Oi the iailure criteria described n 310 ( fvl!< i 5.303 or ir, 310 C1n�-Z 15.304 exist. Any aiiure criteria:net evalua:ea are indicated beloi,lr. Comme its' i _— --- a• . j B) System Con.diilonalhf Passes: , One or more system components as described in ttiF { ,o-:,ditio,na` Pass 'sec?ion neec to e replaced or repaired. _..ne system, upon comp etion of the t :vice;;,snt or repair, as a c,r r o y,ems ,. the Board c, Health, •av°il pass. li Check the box for"yes% "no" or"not dete ir.rned' (Y. N, ND)fcr the foi owing staie,^1.nts. ; 01 determined,' please e.,plain. he SeJtic tank is metal an c over 20 years o!d or the sepflc tot (whether m ta. Cr In IS ' st'cctU ally unso ind e'x`).;b;t_ Sub.antial infilt'a ion 0"?xfiltr atiCn cr tangy . ilu,e ,S im.mif:ne� ,f 1v11. ;Ga S She lion if ,e exiting ink is reulaCed with a com.plyin:g septic lank as apprc`.e Bccrd of !--ecltil. ne i 'N *A meta! septic tank evil! ass insrection if It ' t 'Ir i �t i (III :II i p� s s.ru t� a s U d e2<t;g G if C r of Lom?liance indicating that the tank is less than 20 years old is a.V Ir iabla. a y ND ,Explain beidvd): t ; IJ'ns-C9/C8 - J C c. i Commonwealth of Massa chuset"•:s ;WM0 `title 5 Offic'al Ind ped'on Form Subsurface Sewage Disposal S stem Form of for�oluz^ta v i�ss 3 lii I _- p Y \ i li roperYy,-address � — --------- ----- ----- Il _ �aS�iti�' �f Owner O,✓he's dame,----------------- ----- - ------- -------- ---- informai;on is a,ne�i reouired.-or every page. CityT,ev r• ----- --- -- - -- - - --------S:ate Zip Code -'a- � Gat'tificatian (curt.) -- 1 B) Systeim Conditionally Passes (cont.'.. ❑ Observation of sewage backup or break out:or high static water level in the distribution ccx due to broken or Obstructed oice's;or due to a broken. settled or uneven distribution cox. `vste.-, t':Ili pass inspection if M!th approval cf Board of Health): !� broken pipe(sl a p_ —� —� re re laced I Y !— !� _i ND xp12in be'o<r': �Ii}il II .II ( !❑ obstruction is removed +_ (\ID - 0 2 below - distribution box is leveled or replaced ❑ Y N ❑ ivy (Exp!air;. oelo::}: II4, ❑ he system.required pumpir9 more than 4 times a year due to broken Or obstruc ed oipe(_) i e system will cuss inspection if:(with approval of the Board of(-;earth): I_ broken pipe(s) are replaced. ❑ Y ❑ N �! ND (Bxpla : 'relci•:,): ❑ obstruction is removed r i _ ❑. 'Y t_ i� �; ND (Expiu,i 1 it E( —.—_ - — —' - -------------------------------- ---------`--- C:) IF rtther ¢�auluatiOn is Required by'he Board of Health• ..-- ----------------- k fi u Con"ons exist which require further evaluation by t:e of Hec;Ti 1 it OrC C O` .,..;: ' Me system is failing to protect oublic :nealth, safety or the env, ronrne� V I. Systemwill pass unless Board of Health determines in accordance with 310 CM,R l5.3Q3(1'( that �i e system is net functioning in a manner which will protect public health, safety° and, ti"+e environment: iu Cesspool or pri/y is a iinir 50 reef of a su fGce v✓2t2; �IC,p�'�I i ❑ Cesspool or privy is '0 feet a bor o t5ins.,,•�� d• r ng veoeta Wetland tland r a I I I ' CcMinnonwealth of l ssachusetts l mom A Title 5 official Inspection Form — 1= Subsur-faca SeWage Disposal System For` Not for\v o u _ ;nss esar � Ls r'Opert:!Address ----------------------------- Owner --' G-s� ----- ------ inform.afiar is p reaui,ed fcr _ ✓/�f — ®/ every page. C>` e — --------- C: :�i own ,. Sia Ziri(.:.COe -+mat Of!n5!3FC.Gn, B. Certification (cont) 2. System vvill fail unless the Board of Health land Public Water Supplier, if any) determines that the sys er. is functioning in a manner that protects the public health. safety/and environm-nt: ilk !'I .II F-1 The system ~as a septic tank and soil absorption system 'S,'kSI a„d the SAS is Ill: 100 feet of a surface water supply or tributary to a surface water supply. a The system ",as a septic tank and SAS and the S AS is �^,,l n a Zone I ar a -ubii �C �r sup`!v.Di y ^ l�'t The system ;gas a septic ank and SAS and the S;,IS is within 50 feet o a rig e G.v.. 1 I. suon!v Weil. ❑ The syse n has a septic tank and SAS and the SAS is less iar 100 fee, but 50 reef or more from a. Private water sup._ly hell`. P✓iet`lod used to determine distance: * This system passes if the well water a:�aiysis, performed at a bEP ce-tified laboratory, ffor c I form bacteria indicates absent and the presence of:ammonia nitrogen and nitrate nitrogen is eq+ua'to o. less than 5 ppm, provided that no other fai ure criteria are triggered. A copy of the analysis musi be attached to this form. 3. Other D) System Failure Criteria A,pplicabie to All Systems: s"ou imcast indicate "'Yes" "N3�'to each of the fcilowing for all inspections; Yes No r— Cf Backup of se`rvage irpto facility or system`componen'. du o Cliff ,f 'i t j L_ clogged SAS or ces,:'-„ci Discharge or ponoinc of effluent o' i to suace l ;�he ercune r;-s4 C� cue tJ SAS o an overloaded or clogged c l a . , cess000l I? r Static liquid level in the dist-ibutio + -f' n box a�o�,�e c�,Ltl-. in, .il c-clogged SAS or cesspool !:quid debts ;n cesspc:off is=ess than below ow inverA or a•a cb1e -10 than flow (,on-ii't'lanwea±lt;; of Massachusetts ,J T'fle 5 0 icial Inspect" o ,n Form - - I Sub-surface Sewage D,isposal System Form Not far Voluntary ;�essn, ;� -!, As Property Ac'c r ss Owner Owner's- am information is , ------------- I , 'I evened Per —-- G s�yP�1 - 6U6O1 'every page. Clhi/Tovin -- S Zip Code , ,_:� (' B. C�erf➢ftcation (cont.) - Yes \1G ::e• Uired UMDin mere than 4 e l t _ • �' F 9 tip es I; �h ate. ea; P1G .d re to c'ccc.ec, or / GbStruCied plpe(s), umber of til lcS Gfiit ire IJ`� �n✓ portion of the !,AS, cesspool or Navy Is be!-, h:on ,`ny.00rtion of cesspool or privy Is wi'hin i00 e'etaiFr _ "Gi" or tributary`o a surface water supply. Anv oo* rilon of a GESSpGOi or pr;VV S Z`'!th:n, a Zo ie 1 cf a public ve!i. J Any Jvi ion, of?.CESS}aG i or p'lVV IS wIhi tn 50 lest pi 8 7r1`✓cie :^a a to r S u, f- ;P :, ! - Any portion of a cesspool or p-ivy is less than 100 ee-bu- area It e r a 50 °ee i :rom a private water Sut.ply we'i with no accep4a.ble Water Ja',`' anal\% i' p- s s. [This system passes if the well water.analysis, performed at i?f P certified ! iaber atory,for feral coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, I" provided that no other failure criteria are triggered. A copy of the analysis and chair» of custody must be attached to this form.] I !he system is e' z ;aril i� u✓ ' a c ospooi serving i'•.y V✓ii, c design ;'ovt cf 2000cJ 'i 0,000gpd. / The system fails. ( have determined zi-12'one or ^'•,ore of ^e above ,aIIL,`e crlteriz exist as described in 3,0 MIR '5.303, uiarefo =he s,ste; ,` The 1-e system owner should contact the Board of Health: to determine ' hat , I' 049 necessary to co-rest the failure. G-) Large Systems: To be considered a large system Che system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you (rust indicate either"yes' or`no" to ea-1 of t e IG.':Gb''Ing; in aGd,,iG , .G „en i' questions in Section D. i �,� ,'�� c 1 Yes No — t;,e sysiern is wi:nin 400 Feet of a surface d!i.nkirto V.B: S ^Gf^;/ 1; Cl the system is kvithin 20'7 feet of a ', - tributary d.Cto loos r i (' M1 �� S n. the system is IoGated in a nitrogen sensitive area (Ir erim `i,ie 1, - E Area IWPAi or�� mar o li G c . - ,ed Zon, of a public h;a.a: s c III If You have answered :,,��; to an QijestiG:, 1r: Section E 'thet.s-n-n iv ^� Or�riSV`eret `yes I� `�?CtiC,1 r� above the large System ,h2.S `o;la`d The o ,i=r systern considered a signifiCant treat under l System in aCCG. :+ nd SeCrlOrl Cr f21,2d fie!` JE^+ICr1 ^ f Lr " dance vr:< < 310 CI�JR i 5.3C4. The sys. . _ = regional Gtf;ce of the Depariment. err pvvl er Snould co ntaG e , Title 0-,c; !- ;t IP C -imonwealth of Massachusetts ' le 5 il Inspection Form — � SubSLirsace Se-wage DtSpesai System Form - Not for Voluntari,Assessmen-s 41 i Prone Address - -- --------------- Owner requir a=.ion is � recuirec°or ..— /J eve, page. City+Town- -- Sta=e - — -- ---- 'p Code `fate of insDcC:fOn G. Check Check if the fo lowing have been done. Yo-u, must indicate`:yes.' or"no" as to each O, :,,a fol'o'::'r;c: ties No Pimping information was prG`;ided by the c:Psner, occupant, OF 3car c 0 4. 1- ❑ `Pere any Gf the system components pumped o3ut in the previous tv,'o weeks' Jfl II ; �_� Has t^e System,received normal '^IOV/S in the preblOUS iLVp`;V'EEk DerlOd? Have large volumes of`,Pater been introduced too ' �e system 'eCe lt!y Or 2S Cv-7 O` this inspection? Were as built plans of the system� obtained and eX2:ilin d? (li *1 v .;e ne, t f� a`railabie note as N/A) v It as tie facility or dwelling inspected for signs of se,:age back up? �Y Ir Was t^e site inspected for signs of break cut? 2 Were aii system components; exciudin9 a.e S:A'S. 'cGated on site? V ere `.^e septic tank manholes uncovered; opened: and the interior of the tar. inspected for the condition of the banes or tees, material of cO-struc�.ion. dimensions, depth of liquid, depth of sludge and depth of scum; 1;V-as the 11facillity owner(algid occupants If different vronn 0'^.+per) provided 1, ✓ Ir:iOrm3+101 On the proper ma fierGnce Of SUOSUfaCB sewageSpOS21 S':-Se; S II The size and location o.i tha Soil Absorption System (SAS) on the site F,es been cetermined based on t , ur� ❑ Existino information. For example: a olan at :he Board of Health De`ermined in the f field (if any of the f?i!ure cr'teriarE.aced to Pa : G I� issue e aporCXlmatfCn Oi � �+� 'distance is unacceptable) [3 � CR '.c 3 `LlJ ' 4Li . f Residential Flow Conditions: N�j m' er of bedrooms (design): — 'Number bedrooms of f n� om i�cuai,. ,G . +, �---- CFSfGN f',ow based or 310 0MR 15.203 (for e<at^le: 110 gpd x . b��rec of ---- + i I Sins-ra+ce i iy IR Ij i Commonwealth of Massachusetts - � I Form itAM— Subsurface Sewage Disposai System Form Not fcr Voluntary Assessments ProYer y AddrBc�cf - ------------- --------------- C�•.ner Owner's Name ----- -- --- ---- -- -- --- information is / roGuired for even,age. Ci 1 Tovml ---- -- - -- --------- Staie Zip Ce p D. System'lnformation -- — Description: � l l©oo G�11oti, Number Of current residems: Does residence have a garbage grinder? !--i es Is laundry on a separate sewage system? [if yes separate inspection recuiredj i Yes - ; !g Laundry system inspected? i Yes Seasonal use? — i Yes CoCt Water meter readings, if available (last 2 sears usage (apd)): Detail::. Sump p u nh o --- ---- -------�J Yes i . Last date o,occupancy; CommercJW.Ilndustrial Flow Conditions: Tyoe of''--stablish<i ent: Design fiow (rased on 310 CMR 1�.203): __-- G;Honc Per dc':.r ----- Sasis o`cesign,fiow(seats;oersons/sp.f-., k --- _ Grease trap present,? , I' t industrial lv aste holdinc t2rl,'•C present? -- Non-sanitary waste dischar4ed to the Title b system') VVater meter readings, if available: TdecO-r. '1c - f - Conqio"iC?nweal.h Cf Massachusetts , t" icW Inspection Form " _ Subsurface Sewage N Subsu_ac � ewrage D: pcsai System Norm -Not or Voluntary Ass'essmer:ts fFrope-, Lid-+-2ss - — -- ---------- ------- ' kGs�� - --- - Own r Owners name ---- ------ — rCY ino�-ma:ion sruired forl�l� -every page. Ci tiiTcv:r -- -- �, ,,�.. p Code Lae nsp System Info `matt l (Cont) Last date of occupancy/uSi?: --- ------------ G2�e i Other(describe below): Generai information 1i lI i, Pumping Records: Source of informatiol-i: ----�` VVas sys ern pur-,'pecl as Dart of the Inspection? — v yes, volume pum;neo: ---- -------- 1 gallora ------ ------ How was quantity pumped determined% ------- -----_-- Reason for pumping: ----- ---- -- - Type of System: Re Septic tang, distrburo, box, =cil abso,ption system l.� 'ingie cesspool bVen, w c e sp DDI I' c Privy. Shared system � r (yes or nc,j ; ,(if Yes. attacm previous i ispeciio records. -u1 f I Innovative !Y.Iterr:afive technology. Attach a cop of ~ the curr, o-pe a io a ;ain;enance contract(to be Obtained from sys erg gin^ v o- 'n pection cf the liA system., by syste:rn c-erato-under r ,. �J. ,ac_. Tight tank. Attach a copy o`the DP 2po a rov�i`. !J Other (describe): �� Ti!2`C;JCi_'In:^cCiL-_r=�...:G:-•_ _ :c_ _ i Cc-m,tonewealth of A�assachusetts: Official � e _ �— Title Official ;' .; x � i Form f i= Su surface Sewage D s osal System Form - ,Mot for Vcluntary Assessments ,. UME — r p j kl- ! rroperiv Address -- Ow,ner ------ems_ ��=___------ C vn yec a.- � �reeuredTor -- i �everi cage. Cityirovrn ----- sttoi CocP a e T 1-s� i D.. System Information (con;.) --. Approximate age of all components, date installed T known) and source of information: Were sewage odors detec ed when arriving at the site? � Yes Ell Plo i Bvilding.Sewer (locate o , site plan): it, Depth below grade: D Viateriai -,'con siru,_tion: ust iron ! 1 PVC over(explain): - ----- -- Distance from private water supply we!I or suction line: — — ------ feet - Comments (on condition of ioint_; venting, evidence of leakage, etc.): Septic Tank (locate oil site plan): // Depth below grad! ce: _ Material oT or,str= ction r i 71 J_ concrete ❑ metal —! fiber~lass [ no = - pplye�n :e;.e L c;her (exola;. , ,F If tank is metal, list age: o Is ale confirmed by a Certificate of Com dance? atacn — �dlil� P� "' ( .. cope or Dirnensio�n--- F Sludge depth: !I I_Ins..231 F �f i Corn9mormfeafth of i ection Form `u-�a_=— USsCrC 'EldaUe DlSCOSal System Form �C'for V O!Ll`ury 1SsESSrI'2itS Rope v Ardress� I —tom' ---- --- ------ — Owner 0 n-r;ar's fame� — ----- -. ---------------- ---------— infama:ior+is // 'eciuiied fo- -_- 6), every page. Cityrron^n - — S+:c e p Code�; -- ,^ ------.. cf e O ^.S - ,, Do System hnformation (cent:) -- Septic Tank (cone.) If; Distance from t v"slucc. to 10',f0 O`outile`tee orb f;ie --- -- --- -- Scutt ,Distance from iep of scum to top of outlet tee or bE ie ----- ---- —_ Distance from bottom of scum to .,ottom of cutlet tee or baffle ------ -=-- ------------ Ho\,v +were dimensions Bete-m;ned% ` vle- �`� _��rGe_ vommeni S (on-pumping recommendations, Inlet. and Outlet tee or baffle condl !Gn, S-rL, rcl In es;itv. liquid ieve s as related to outlet invert, evidence of leakage, etc.,- Ii�11 it :Ili i t -- —1 ' i✓� 6� Ct^+ _—�'� — �O C C 7`/'fo — i - t' J '. Grease Trap (locate on site plan): Depth below grade: Material of construction: r COnC:"eke _ metal fEJ2rGi8SS n^' - -- lJ .: veij' e:^e + �ilmen ions: _---_---- 777111 -- i Scum thickness t Distance f-om top o,scum tc,top of outlet tea or baffle -- __-- 1 Distance i1-o-m ,bo. +'tom Of scum t0 bDf C 1 Of Outlet tee Or l2ffl0 —__—_-- Date Of last.oump ng: tSns•GGlG8 ��' c `---------- I -nonweafCamiaassachusetts TIForm Official Inspect' l- I% Subsurface Ser' ap-6 Disposal Sys'teni Form I�lot+or l 0i =rl't #r'/ -issessmen-s �Q. - — - tom/ Pr p 'v ddress —._ -- ------ ------ -- -- Jr Owner Owner rJarn- ' ' - - --- -- — -- -- -- — ---- ----- --.._ infoa`ion;s required for - �ii11 I �, every ace. City/Town -- f P P e - - ----- - .-ate {)C .�_ icmrrerts tcn u �rnping reccmn aaor= rile ^„ o�1t e:tee or oaf�le cone . on�. �. ;-ral lnte,:� i1-o u'd #eveis as related to ou iet invert; evidence of ieakF_ge Tight or H ding 'Tank (`ank must be pursped at time of inspection (locate or. site p#G # Materiaf of cons iCt10n: d( 1 t conCr�te.x l8:al q t13� 4#ass E oo{�i�t :YleOe { } i3Djmensictls:'' — Cacacity' - Cv'o}s-- ------ --—-- Design Flaw: eal ors oeo�� — - -- -- — Alarm o#esen.:. Yes 1Jo -- - Jar=m.lei ei -- - Adam Nork n car: ( sec I. I DateW last purr# inc: Ccm;ner cord_ion of alarm ano float s,,,t„hes e C.; Attach, COPY of Current pumping cCntract (squired). Is coov a'tacheG'7i F7 �'cs ,. ;Sias•^9iCP �f i Corn---ion eaath of Massachusetts I . e i ' l Mspection Fore — i<, Subsu face Sewage MsP osa; Systern 'orn. N oa- ^�/��/�) /J /-/� a/:or Lc(un`ary Assess rents ; A Prop 9,t'd ",a' -- --- . ;- ctress ----- ---. --- ------- Owner Owner's iimarn ---------- -- -- in`ormation is -- - ever,/ed fo (T v'N�J _--. AY ever,gage. CitylTovtn (T Ste':e %i Coce -- ----- _ -P _oea ns,e .on �►�p D. System IngOrmatiot1 (car7.) - Distribution. Box (if present must: be opened) (locate on s°te plan), i { Depth of liquid level above otatlet invert CComment's (note if vox is level and distribution to outlets equal; anv evidence of sc!=ds carwo':-e . an evidence of leakage into or out of box, e c.): X0 t Pump Chamber(locate on site plan): Pumps in working order: =; Yes Li do Alarms in working order: —II Yes i�i No Comments (note condition of puirnip cha,Tlber; condition Qf pUm7S and appurtenances. -aiC.): Soil Absorption System (SAS) (locate on site plan, excavation not;e -- — t if SAS not `ocatea, explain �vhy: �s :Sins•09/08 : Commonwealth of MassaChLrSMAS r =� Title ill Inspection Form Subsurface Sewage Disposal System Form -Not for Voiuntary Assessme;;ts Property Address /! / - - - --- --- ---- i!' Owneri --- wwners Name information is�'. required for _-- C%a✓�!/1/J _ / �/T �/p�1� % —� ®� ----- every page. Cibf,' own �---- -- ±e � -- --- Spa ZL.C;:de f at= ;so�ciicn De Systems Information "Cont.) — -- Type: :e chit;,_ rr _ / �✓ 01 ' -�a h-� [❑ leaching chambers number: ---- -- u 'leaching galleries number:, ber:, -------------- C leaching trenches number,-length: - ---- [i C Ieach ng fields number, dimensions: — El cverficky cesspool ' LJ innovative/alterna-uve sys:e, I j --- --- --- - 'I Type/name of techna!ogy: — --- - i omments ( Ote Condition of soil, signs of hydraulic failure, level of ponding, dam'D c i, CC ,d :O,-i of 111 vegetation, etc.;: ;✓�� S -vs ---°-�-_ l�f �i�a fir, c' �i Z��a aye .. : 1 Cesspools ( esspool must be pumped as part Of inspe^t,o-:) (locate on S to plan): 1 f (,umber and conficur=:ion : . Depth -top of!aiaid to iniet invert �r Depth of solids'la:ver DBtit.i.o1 scum ia\/er 1' ime nslvns of G8 SpCO� Materials of construction Indication of groundwater inflow 5 0-c:= 1, II r -- -- -- - -- -___ _ - I� � I: t �.>orm—nonwG-'s` fth, oiNlassaGhusc`t9 Official inspection a„ ,. 050-4 ° orm Subsu ~ce 5ev�ay� +iri�osaf Syste .. =orm �`Ict for lfo?un. y As:� t� ses s rn,en O+/ ^- Glvner's Na-e I ' ----- - in'ormafion required for . every page. City,70wn -- - - -------- Comments (note condition of Soil, S( r'iS ;! aulli g. of h.dr uc failure. level of Bonding; rondiLcn ;e^e cn. 9 etc Privy (locate or. site plan): �Mlate;-ial�s of construction: . ------ ------ - -- Dimensions of solids Comments (note cond:°lon of soil, signs of hydraulic aa;are; level of poriding; condition of vece:aticn; etc.;: i Ij 1 t i5ins•p3-pg Tile Commonwealth of Massachusetts ection Form • - s — S€ bsuKace Sewage Disposal System Form - Not for Voluntary,>,ssessn,ents ?> Prcperiy Address Owner n Uvrle — ------------ _, s\ame information is - ------- ------- I pp i required for ill! every page. City Tc%,vn -- Mace �.ip Code --_= —7`------— -- _ --- — D. Systems ��f o-rm a$I—(,)n (c�fii: y — �! Sketch Of Sev doe$ DisPosal SY�'stem;: Provide a view of the s e,;r�pe ti� disposal system, including tiCS -- J at least two permanent relence 'andmarks ,ter benchmarks. Locate all we-Ps within 100 fee. Lec_ e %rV here p i i 1VctC" sjooly enters the building. Check one of tie boxes belO,,^.. `I Inc-Sketch i-' "he area below r—I. drawing attache0 separatel}' i i i l sCre<»-�d ' C Oq o: 672 -a Ili I� , �de- 3 - t ----- if i7 COM-monweafth of Massachusetts Title Subsurface SeWage Dlstaosal SYstern Form -Not for V0 u ,farj Assessments } MP A i ------- _._— ----- --------- Prcoeriy^ccress -------- ------ li i Owner `'.wner's Name � -- ----— — — -- -- -- -- information is a recuired for 06L60 every page. City,'Town -- — --- c — ----- State Lip Code .'2te lilSpe iiQ;", Site —:-xa",: 6 ❑ Check S o~:e C! .Surface water c lE • Check cellar ❑ shalio'"ly wells /t pate Estimated depth TO high orcund water: - / ---- -- ------____-- I��l i methods used to de-ermine the high round v/ ?!ease indi a!' � �< g �.'ater eievation` is Obtained from system design, Mans on record c If checked; date of design PIGS i reviewed: -- _-- Date i 'Observed site (abutting; property/observation hole within 111 50 fleet of SAS; , «t' Check:cd with localNarri of Health exOlain° Checked with l:oca! excavators, installers - (af ach documentation) L7 i Accessed iJSiS database -ex elGin: ' .,You must es ibe how you establisheJ the high ground �vater elPvatiori t ------ Before titina this tnsPection Rez)o,.t, ;ease sco F2e ar,�Carrr,oiereness ------- .G,S-= .� Checklist on next page. Title 5 Offici 2J L-ScerC:n PCrs: -i th of Massachusetts off` � 'Ut4j ! SCE SE'af.T.,ge f isp� osal SystE?Y1'e-OEf1 ' Not f01 /OiL it:(ji ASSP,SS E^:j IPro e^ Address J / - --- ------ -- - --- --- Ki }.' Owner r'N'Iler'S Nam ---- ----- ---'- '--- nfo ma°ion is g 4 — yi eeuireo fo,r — _ U.✓4 s �/l I; every paoe. city"IoHif'i -- ----- _iate Z;P Code tiaT� �f is^SD�CtiCn E. Report Cannfil-ateress (',"hecklisnt iSP' `-tiOri .`.U'M i ery. Ar.. B. G, D. or t_ checked liispectlon Summary D (System Failure Criteria AoalICable to Alf Sys-toms) Coy i r efeC Lvrsystem 1 ifoz'na ion— `s"kirnated depth to high g oundwater t SkC@fo of Sewage Disposal System either dray;n on ?age 15 or attached in secarcte file (a i i . II n i •4 I ri I'Ilj' II t ins%o9foa T'L:io�_ I1 . osY CAT N SEWAGE PERMIT NO. dan l7 f[a VILLA SS I N S T A LLER'S NAME i ADDRESS Llo � il 's „Le6e r QV-. 3 l/ /i 3,1 11 U I L D E R OR OWNER t Of h co ReA DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �a r70 !h 92 6Z �bz SZ 9� a asoo14 ao � �� `e d - THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town.... ...............OF.....B rns,table. Applira#iou for 0hipaii al Workg Tomitrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ` - b1• �^= .. .....Hyanni s r - ............................................................ L ATdres tCaricorn rus . 6 •p Ra ........ 7 -----•-•........ -_... o Lot o.8 ................. W Steve Lebelowner Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........3..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building Ra�ngh.............. No. of persons........................_... Showers 2 — Cafeteria p' Other fixtures ------------------------------ - W Design Flow............55---_•_•___••-•__-___-•----gallons per person per day. Total daily flow.........3.3Q...........................gallons. WSeptic Tank—Liquid capacity 1_Q-Q.Qgallons Length-_8.'.6".._ Width...... '.,D Nameter________________ Depth..5!$"... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area............_.......sq. ft. Seepage Pit No...1............... Diameter---6..-.__..__..... Depth below inlet........ .......... Total leaching area... 66.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by......UC1X:adge--- 11g1T122ring____._____ Date------1.1.-257&1_.......-_. Test Pit No. lK.2.9.9_.minutes per inch Depth of Test Pit......1.2......... Depth to ground water.=R...anCounterr f3. Test Pit No. 2...Nlk....minutes per inch Depth of .Test Pit---N/A........ Depth to ground water....xVA........... ed P ----------------------------------••----•---------••------........------------------••-•••-•---•-•-•........................................................ 0 Description of Soil........... •"•-2......---•L9alfl..&•--T.Q2P? 0,i_1- v .............._••......-••----------•-----•2.--1-� ---••Medium__Yellow_.Sand--------------•---•-•-•---------- • . . . . -• . • -- -- . . ----------------------------------•--•-.10.'.-12- Need......w.blt.e...Sandl._traces=---af---crav_el/nc...v&ter---at...1•2 V Nature of Repairs or Alterations—Answer when applicable............................................................................................... .................................................•--•-••-•---•••-•••--•-•---•--•----•......---••-•-••••-•-••-•.--------------------•-----------•--••....-----•--•----•-•-•----•---••-•................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions-of TI HE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by he board health. ned �... .. 1. D e Application Approgof .................................................. ............................ -.4 ..31...1_�.......... Date a Application Disap the following reasons:..-=---••---•-------------------------------------------------•---------•---------------------------------_..... -•-•--•----••-••-•......... . . •...........---•----••-----••-••-••--•---------•.........._ Date PermitNo......................................................... Issued....................................................... Date " ice`y�/•/ _ �`�tj No......................... Fss.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .. .................OF. ^--r�^ --.a'h1 e ..................................------------................................ Appliration for Disposal Works Toustrnrtinn rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ..h ....�'':". ' �°..�, ....... ... ........rs' is ............•. •........................................ .. -- t Location-Address or Lot No. Capricorn r:e l tv rust 765 2almouth Road. ittranris ----•--•----...---•--..........................:....•---------•--------•--..._.._........._...... ......•••------••-•-------•••••••••............_................••-•••......••-•--............-•-- Owner Address w 'iteve lobo Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........... ...............................Expansion Attic ( ) Garbage Grinder ( ) p`1, Other—Type of Building .........?............... No. of persons............................ Showers ( ) — Cafeteria ( ) Q, Other fixtures ................................. • W Design Flow..............55..55..........................gallons per person per day. Total daily flow.........3330...........................gallons. 04 Septic Tank—Liquid*capacity.1.0Q-0gallons Length.-B.'.6"... Width.._..1.�_'lD Diameter________________ Depth...5.!.�"_.. W Disposal Trench—No..................... Width.............._..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No................... Diameter...6.._.......... Depth below inlet........6_......... Total leaching area...2.66.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _.,] rlrocl�� ot'�f`,. r� 1 1 Percolation Test Results Performed by...... =----------------- =•-------.--.. Date_........�_-.2�.-8...--.-.------ F`�j Test Pit No. l<_.2.4,.0..minutes per inch Depth of Test Pit......1.2'.._.._ Depth to ground water.none...encounter- Test Pit No. 2---TVA----minutes per inch Depth of Test Pit...DI/A........ Depth to ground water.__r/A........... ed ---------------------------------------------------------------------------•••••••--••-••••-.--•--•.... •----------- ---•-------------- •------- ._.......... ••- ODescription of Soil...........Q.----2............�toam...&...!-onsjail.............................................................................................. U •••-----•---••..._....-•--•-••••----------2.'--1Q-'----•-- ed u ..Y s a �---------------------------------------------------------------------------------- W •--•------------------------------------ 0.... 1 ..----- Ke 0- Ylh_Lte••-Sand/txa ae s...of---r-rave 1/na...wa,ter...a_1.--_12 UNature of Repairs or Alterations—Answer when applicable............................................................................................... •----------------------------------------------•-•--•••-•••••••.........._.....................--•-•-•••-••------••------•-•--••----•----••----••-•----------------------•••--•--•-•--••--••-----••-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of':i 12 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed--� ----- -------------•- - •--•-- --•---..:..�.. �. Date i Application Approved By�_._._._____ G -------------------------------------------------•--•---------•-•-------.---.--•--- Date Application Disapproved for the following reasons-----------------•----------•---------------------------------------------------•--------------••......----•-. ..................................v..................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ot.71....................OF.....�.? 1:" :1.o .............I...... .................................................... (Intif iratr of TrrnapliFanrr THIS IS TO�C ERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by..................................... ..........................................................-..................................................................................................... ,.. s Installer at-- .................- L.;� -yy.- -F.--- ,--- _4 --------------------- --------- ---- =---------------- -------- has been installed in(accordance with the provisions of TI j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated`:.:_-.......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.-•----•............................•---••---•------•••...._.....---••-••----•-• Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r No......................... EE........................ Disposal Works %'unntri inn rranit Permission,is hereby granted F `.._ , J to Construct ) or.h2epa(r,( ; an,Individual. Zew age Disposal System / atNo.......-•-••--..............................................................................................._....------.. _-. /_, .-..---- -- --------------- Street // '1 Irf[' r� f/� . as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... •-------•-••..........................•-------------------------------------•--••-------•---•--....•--•-- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS • �n { E 00 Z'60 Si s N $ ' 3oiL. �x 41) P, D z4'O 23t r to 'r 27"t �4 f lit, �13 f LaN (Zg , �v qo ' 10 lot ALBERT � L qA. WIDTH IGL'7' No.ira l n � ia> O r lo' Su � S. E3 LEGEND OF CERTIFIED PLOT PLAN EXISTING SPOT - ELEVATION Ox0 EXISTING CONTOUR --- 0 0� XHN cN FINISHED SPOT ELEVATION �,,-7� eErt H 11AQAJ i FINISHED CONTOUR 0 C IN APPROVED > BOARD OF HE AL L �No su SAgh 8149 A o ASS* DATE AGENT SCALE= t " m 30' DATE % /Vote LDREDGE ENGINEERING cam CLIENT FR "; o I CERTIFY THAT THE : PROPOSED EGISTERE REGISTERED JOB NO. 42- BUILDING SHOWN ON THIS PLAN CIVIL LAND Ap CONFORMS TO THE ZONING LAWS ENGINEER URVEY OR.BY8.,,...._.,. . ._ OF BARNSTAB E� ASS. 9Y•CH 712 MAIN ST. HYANNIS, MASS. SHEET." OF .Z. DATE G. LAND SURVEYOR E/------------------ TNER THE.SEPTIC TA/V/C OR 20 FT. M/N. L--ACN//VG P/T ARE MORE THAN /2"BELO�� ` ..�iRA0E, f1 24'O/AMETEK CONG'RETE CDYE����'•� S,NALL BE BROUGHT TO GRAOE.CciN EXTF/A CONCRETE i 4~PVC P/PL tirEAVY CA 57' /RO/Y 93E USED ` �L=90.o CDYER� Yg"?ER FT. a'• C'ONCRE'TE 2'• M/N. GRApE COVER CLEAN SANS 2'LAYER _ /Rom PIPS 1000 GAL. r a o MIN.P/TGX D/ST. r i • • • • • r • • ° •O WA SHED 57ONE SEPT/C TANK o a I • • • • • ♦ra a q :'. BOX p • 1 � • • • • • � a A e Q • s� v6• 1 • i�FEC'T/VE � � . • 3�4 - � /�2 • n 1 • pLewTf/ • • • v ; WASHED STONE � v • r • • � • • i 1 �e o e Jt�3as a A6Qoe • 1 • • • • • • • • .p D � PRECAST SEEPAGE 4-1 1 C3.P. D" v��o• r • • • • • • • ' e•• o P/7 0R ZVu/V. IA,;ezAT ELEYAT/ONS i U �g Gy P p " -EL Bo.o - s /NYERT AT d�!/LD/N�r g� o FT. �>� 8�,B Fr �{-rcAPr���� �49 /•�• D . I D FT. O/A/+�/. C(sFE TAauc..oT)0N� INLET 'SEPT/C Ts41 O/JTLET SEPTIC TANK } c�� � F.T GROUND y{r�ITEK TADLE t INLET O/ST/q/®!!F/ON BOX SECT/OJV OF' 007LE7DI3TR104MONEOX 8G.2 F7 SEyt/AGE O/SP4SAL SYSTEM INLET LEACHING /�/T AFT. T�IBtJLAT/D/V LEACH!/VG PIT o//yENs/on/ A 3 PT. DESIGN CRITERIA sc�L E ' %" /=o DI�f.Eas/o/v 8 Ft. D/i�fENS/ON C 4 FT. (l`/ t4) NUMBER OF BEDROOMS 3 SOIL O " GARBAGE DISPOSAL UNIT 0 — LG SOIL TE$T F TOTAL E3T/MG4TED FLON/ 330- 0,4L.IDAy 'DSO I L TEST #/ SO/4 TEST*2 NUMBER OF LEACNI/VG P/TS 1 f`FLEY. gg 4 �"E.44 PATE OF SOIL TEST ( I �S'�I SIDE LEACHING PER P/T I gB SQ. RT. CAM 2c RESULTS AVITNESSED 5Y BOTTOMLFa4CN/NG PER P/T�$Q. FT. _ 0 SUBSOIL P-emcaAA-r/ON RATE,*/ � M.1, I/NCH F'EhCOLAT/GN RATE2 TOTAL LEACH//YG AREA 2 SQ. FT. rQAc�s R,e5z-g�EGE4CMI/VGAREA�SQ. FT. z 4' AAeDGPAvEL 2.0 �N OF /VI1=D LOT 54 - wA�c F�l-.1G orb ]OHN S9 c ���' AL Eft ' -I'l �f. ,o MORSE a IIo.'"874 c _� a No.10951 0 �M, EL DREDGE ENGINEERING CO,INC. FQ/gTER� Q APo ��ISTGi ��'/� 712 "A//Y S;r SUR �_�� �+-,- � ® No GRouND Yi/ATER ENCOUNTER45O HY,aNN/J, MASS. ' ' (� GROUND YvATER AT ELEI/ - .I08 NO. �1205 SHEET Z OF 'z-