Loading...
HomeMy WebLinkAbout0023 ABBEY GATE - Health �23 Abbey Gate Cotuit A= 022 — 110 I r I� 1 �� •'-- --�- ! Jj� TOWN OF BARNSTABLE LOCr1TION 0�.3 E�l/U C0.z�G JRUdLd SEWAGE # VIL12AGE COLA 7 ASSESSOR'S MAP & LOT oA,2 !/0 NAME&PHONE NO. :2ailfS IN F:70`'d SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS .3 OCL�u[LL OWNER 77oShluQ 4- �aZ,0-/e-ic—� #4' /1 dart e w PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by f � T O a / 32 1-7 g 3 3 O y 33 S-7 s S St Yo 3 �� TOWNZ BARNSTABLE LOCATION �'1 17�J SEWAGE # -VILLAGE Corru � ASSESSOR'S MAP & LOT QDa- 11"U INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /90 LEACHING FACILITY: ( pe) 4X(4 P+T ' of L. C44'%*4e) NO. OF BEDROOMS 3 BUILDER OR OWNER Muth Cow S+�1V PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by�nS/�w'�l0^ �. Foy c� F o a - A 3 i 3a !-7 0 5S� lqol TOWN OF BARNSTABLE LOCATION �is -% SEWAGE "/" VILLAGE C& v. l ASSESSOR'S MAP & LOT r INSTALLER'S NAME&PHONE NO. '/7 7 J-- 9 '7 7 L SEPTIC TANK CAPACITY %d LEACHING FACILITY: (type).2 -r-�--;, I- C- (size) / `,�•-� tr- NO.OF BEDROOMS JAJ 7- BUILDER OR OWNER °'' L5 PERMITDATE: a°-* COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of l/aching Facility Feet Private Water Supply Well and Leaching Facili;etl&nds any wells exist on site or within 200 feet of leaching facility Feet Edge of Wetland and Leaching Facility(If any exist within 300 feet of leaching facility) - Feet . Furnished by r �, � r ' ! + ') 1'�''�W, s Wes' 3a� . „� .. " ,�� � ,� f 5,�. �. � , A ,. t� it �f ._� �0�' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A I CERTIFICATION 211 Property Address: 23 Abbey Gate Road / d Cotuit. AM 02635 E Owner's Name: Joshua&Patricia Lindauer 2� i riI Owner's Address: Jet Date of Inspection: March 30. 2006 w.= CQ r Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ✓ Passes Conditionally Passes Nee s Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: April 3. 2006 The system inspector shall subracopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional.office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use.. Title 5 Inspection Form 6/15/2000 page 1 0 Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Abbey Gate Road Cotuit, MA Owner: Joshua&Patricia Lindauer Date of Inspection: March 30, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a.broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a 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 7 obstruction is removed ND explain: 2 f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Abbey Gate Road Cotuit, MA Owner: Joshua&Patricia Lindauer Date of Inspection: March 30, 2006 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 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 environments _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the.SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Abba Gate Road Cotuit, MA Owner: Joshua&Patricia Lindauer Date of Inspection: March 30, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"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'/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to.this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as describedin 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 System: To be considered a large system the system must serve a facility with a design flow of 104000 gpd to 15,000 gpd: You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23 Abbey Gate Road Cotuit, MA Owner: Joshua&Patricia Lindauer Date of Inspection: March 30, 2006 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. ' 5 f Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 23 Abbey Gate Road Cotuit, MA Owner: Joshua&Patricia Lindauer Date of Inspection: March 30. 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#1 of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes.or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow(seats/persons/sgft,etc.); Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): . Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: a leach field was added in Jan. 2001 -per as-built Were sewage odors detected when arriving at the site(yes or no): No 6 s Page 7 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Abbey Gate Road Cotuit. AM Owner: Joshua&Patricia Lindauer Date of Inspection: March 30, 2006 BUILDING SEWER(locate on site plan) . Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 8" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete -metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Abbey Gate Road Cotuit, MA Owner: Joshua&Patricia Lindauer Date of Inspection: March 30, 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-Box was level no solids were present PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I, 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Abbey Gate Road Cotuit, MA Owner: Joshua&Patricia Lindauer Date of Inspection: March 30, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: I-6'x 6'(1000 gall ✓ leaching chambers,number: 2-leach chambers w/stone 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.): The leach pit and the chambers were drv. There did not appear to be anv signs of failure Used camera to inspect CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no)`. Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL•SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23.Abbev Gate Road Cotuit, MA' Owner: Joshua&Patricia Lindauer Date of Inspection: March 30, 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks: Locate all wells within 100 feet. Locate where public water supply enters the building. Q t3 •o �` 1 3a 1-7 3 a 3S 3 3 Sa y S ss' qqo • 10 - Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Abbey Gate Road Cotuit, MA Owner: Joshua&Patricia.Lindauer Date of Inspection: March 30, 2006 SITE EXAM Slope Surface water. Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to.determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing qpproxiniately 20'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the systemi the inspection and/or this report. 1.1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION I'dAP Property Address: 23 Abbey Gate PARCEL ` h ®�. Cotuit, MA 02635 LOT Owner's Name: Ruth Constant Owner's Address: 200 Swanton Street, Unit 617 Winchester, MA 01890 Date of Inspection: June 16, 2003 RECEIVED Name of Inspector:(Please Print) James M. Ford J U L 0 2 2003 Company Name: James M. Ford Mailing Address: P.O. Box 49 TOWN OF BARNSTABLE Osterville,MA 02655-0049 HEALTH DEPT. Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Need urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 21, 2003 The system inspector sh\suba copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes-and Comments. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 L Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Abbey Gate Cotuit, AM Owner: Ruth Constant Date of Inspection: June 16, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Abbey Gate Cotuit, MA Owner: Ruth Constant Date of Inspection: June 16, 2003 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23 Abbey Gate Coto, MA Owner: Ruth Constant Date of Inspection: June 16, 2003 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 23 Abbey Gate Cotuit, M4 Owner: Ruth Constant Date of Inspection: June 16, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: S Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last.2 years usage(gpd)): 2001 -483,000'gals.;2002-297,000'gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAIJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 1999-per treatment plant Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A new leach field was added in Jan. 15101 -per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Abbey Gate Coto, Am Owner: Ruth Constant Date of Inspection: June 16, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 8" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate)' Dimensions: 1000 gal. Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Abbey Gate Cotuit, MA Owner: Ruth Constant Date of Inspection: June 16, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: - Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were Dresent. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Abbey Gate Cotuit, AM Owner: Ruth Constant Date of Inspection: June 16, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gal.) ✓ leaching chambers,number: 2 leach chambers w/stone 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.): The pit had approximately P of water on the bottom. The bottom to grade was approximately 8. The leach chamber had approximately 2"of water on the bottom. There were no signs of failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Abbey Gate Cotuit, MA Owner: Ruth Constant Date of Inspection: June 16, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Q f A 13 O a i 3a 1- a 3s � , e---L 3ay y 33 -7 ss qo 10 e Page 11 of 11 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Abbey Gate Cotuit, MA Owner: Ruth Constant Date of Inspection: June 16, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20' +/- feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE ASSESSOR'S MAP & LOT-0r INSTALLER'S NAME&PHONE NO. 7 4 SEPTIC TANK.CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS ✓ '�% —a �' /°: T BUILDER OR OWNER '! PERMIT DATE: COMPLIANCE DATE:1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of 'aching Facility Feet Private Water Supply Well Leaching Facility any wells exist on site or within 2W feet ofaeaclung facility�e�tlds . _ Feet Edge of Wetland and LeachingFacility(If any exist within 300 feevof leaching facility) -. Feet to N ti � �i COMMONWEALTH OF MASSACHUSETTS Z'qA\3Ao\ TI EXECUVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �s TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 23 Abbey Gate ` Cotuit 23, Owner's Name: Ruth Constant rllAp ` Owner's Address: 200 Swanton St. #61 7 Winchester, MA Date of Inspection: /--�/� —Q / LOT Name of Inspector: (please print) W i 1 1 i am E_ - Rob i_nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1 089 Centerville, MA " Telephone Number: (5 0 8) 7 7 5—8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below.is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Sect' 'n 15340 of Title 5(310 CMR 15.000). The system: —� asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _42 , Z Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heal ter DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 Abbey Gate Cotuit Owner: C _ Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. 71have Passes: 1/ 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: , 661110 S d 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 wil l pass. Ans Arer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please exp in. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally uns und,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the exi ting tank is replaced with a complying septic tank as approved by the Board of Health. • metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance in icating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or oblchvcted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will p inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 Abbey Gate o ui Owner: Constant Date of Inspection: I—/C s 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 fail' g to protect public health,safety or the environment. 1. yytem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the stem is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. Sy tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 s rface 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. q I 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 front 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 acteria and volatile organic compounds indicates that the well is free from pollution from that facility and he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ailure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of,I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 Abbey Gate Cotuit Owner: Constant Date of Inspection: D. System Failure Criteria applicable to all systems: ' You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ D/ 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 t,/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool/ l Jiquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ?/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 1/Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. TzAny portion of a cesspool or privy is within 50 feet of a private water supply well. /Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as w 5 r 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 gp You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is 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 ou have answered"yes"to any question in Sectiva E the system is considered a significant threat,or answered " es"in Section D above the large system ltas faded.The owner or operator of any large system considered a ignificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 1 .304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23 Abbey Gate otuit Owner: Constant Date of Inspection: /'I G G C Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o /Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? r/ 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) t/ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? _/_ P d 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 thhe baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? v — Was the facility owner(and occupants if different from owner)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: Yes no /_ Existing information.For example,a plan at the Board of Health. 1/_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 23 Abbey Gate Cot-u i t Owner• Constant Date of Inspection:'/ /�--B / FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Z)`/6 Number of current residents: ! Does residence have a garbage grinder(yes or no):,6 Is laundry on a separate sewage system(yes or no):/t_D [if yes separate inspection required] Laundry system inspected(yes or no):Z, Seasonal use: (yes or no): A- b Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): 1L o Last date of occupancy: COMME /hen DU RIAL Type of estnt: Design floo 10 CMR 15.203): gnd Basis of de seats/persons/sqft,etc.): Grease trapyes or no): Industrial wing tank present(yes or no): Non-sanitadischarged to the Title 5 system(yes or no): Water metes,if available: Last date of occupancy/use: OTHER(describe): IV6 G GENERAL INFORMATION Pumping Records Source of information: ,J Was system pumped as part of the inspection(yes or no): 4,0 If yes,volume pumped: allons--How was quantity pumped determined? Reason for pumping:T e.0/iz c3 r 3 d TYPE/OF SYSTEM eptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):/JJ—O 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address?3 Abbey Gate Cotuit Owner: Constant Date of Inspection: BU DING SEWER(locate on site plan) Dep below grade: Mate als of construction:_cast iron _40 PVC_other(explain): , Dista ce from private water supply well or suction line: Co l ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:`1/ (locate on site plan) Depth below grade: Material of construction:✓oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) I Dimensions: / X & Sludge depth: Q Distance from top of sludge to bottom of outlet tee or baffle: ­J/ — Scum thickness: Distance from top of scum to top of outlet tee or baffle: �5 , Distance from bottom of scum to bottom of baffle: outlet tee or bae: p How were dimensions determined: n r e h- )4 6 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relate to out invert,evidence of leakage,etc.): F GR SE TRAP:_(locate on site plan) Depth be ow grade:_ Material o construction:_concrete metal_fiberglass polyethylene_other (explain): Dimension Scum thic ess: Distance fr m top of scum to top of outlet tee or baffle: Distance fr m bottom of scum to bottom of outlet tee or baffle: Date of 1 pumping: Comme s(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid.levels as rela d to outlet invert,evidence of leakage,etc.): t 7 Page 8ofII ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Abbey Gate COtuit Owner: Cons t a n t Date of Inspection: TIGHT 5 HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) e1w 1� Depth b ade: P Material o construction: concrete metal fiberglass_polyethylene other(explain): Dimensio:s: Capacity: allons Design Flow: gallons/day Alarm Fesent(yes or no): Alarmvel: Alarm in working order(yes or no): Date ast pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 6 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.): PU P CHAMBER: (locate on site plan) Pum s in working order(yes or no): Al s in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): !A 8 Page 9 of 11 F OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) - s4 Property Address: 23 Abbey Gate ' Cotuit Owner: Constant Date of Inspection: r6I SOIL ABSORPTION SYSTEM(SAS): {locate on site plan,excavation not required)f ' If SAS not located explain why: Type leaching pits,number. i leaching chambers,number: 2-- - leaching galleries,number: " leaching trenches,number,length: * leaching fields,number,dimensions: # - overflow cesspool,number: k, . 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.): ) 'r f U a o -�rd' l,�'++�, F' � o�-- �' L� � f 0 r,. L'� �,p.✓�C� p to • CESS)ed S: (cesspool must be pumped as part of inspection)(locate on site plan) s Numbconfiguration: " Depthf liquid to inlet invert: Depthds layer:Depthm layer: Dimenof cesspool: Materconstruction: Indicagroundwater inflow(yes orno):Commote condition of soil,signs of hydraulic failure;level of ponding;condition of vegetation,etc.): PRIVY: (locate on site plan) . . Materi s of construction: Dime -ions: Depth o solids: " ' Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Abbey Gate Cntuit Owner: C=Q t ant Date of Inspection: /G—6 l SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 1 i 3 taa � l a aOia oo © 76 3 �aaoL 71 10 Page 11 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'k PART C SYSTEM INFORMATION(continued) Property Address: 23 Abbey Gate Cotuit Owner: Constant Date of Inspection: SITE EXAM Slope Surface water Check cellar ` Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: " Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) y Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established he high ground water elevation: I�d f. ' s ' 11 No. Z000- j Lo 3 Fee$5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppYication for Mig;pooaf *pztem Construction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 23 Abbey Gate, Cotuit Ruth Constant Assessor'sMap/Parcel pZZ-_6 i 10 200 Swanton St #617, Winchester Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) New Title-5 leach system consisting of a D-box and 2 concrete chambers with stone all around. 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 oar of Health.. Signed ��/ ell Date Application Approved by U(.mn L� �C' imp Date la/3L9 f 0Q Application Disapproved for the following reasons Permit No. ZW0-7(n3 Date Issued j a Jai/o o --------------------------------------- No. : Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Tipplication for �Dioponl *pztem Conttruction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. �Ae3ssoP'§' Spe/farcegate, Cotuit Ruth Constant ' 200 Swanton St #617, Winchester Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Im. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) New T ale_5 - ,each system rrnnsi atti nq of a 11_hnx and 2 concrete cbambers yaitl•1 stone all gntinrl, 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 Board of Health. Signed ,r'7� Date 4-1:24 F-t:�:.8 Application Approved by Date T l.aT0o� Application Disapproved for the following reasons Permit No. �7 Date Issued —————————————————————————————— --------- THE COMMONWEALTH OF MASSACHUSETTS Constant BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal.,S.ystem Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm_ E_ Rdlf l'tson i_c SPr.vi_eP at 23 Abbey Gater ^ti-ettl' t ""has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.t r�hr� , dated Installer r.�..�—�"'r��$�st3 Designer � The issuance of this permit shall not a construed as a guarantee that the syte3ta will function as des ned. Date Inspector / 1. i +t v ——————————————————————————————————————— No. Fee$5 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Constant x1h6pozaf *p!5tem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 23 AhhPv rats_ Cntnit 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. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by R MOM NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WTTBOUT DESIGNED PLANS) William E. R o b ins on,S iweby certify that the application for disposal works consuuction permit signed by me dated concerning the property located at 23 Abby Gate, Cotuit, MA meets all of the following criteria: • The failed system is connected to a residential dwelling only. 'There are no commercial or business uses ted with the dwelling. The soi is classified as CLASS I and the percolation rate is less than or equal to i minutes per inch. There a no wetlands within 100 feet of the proposed scpuc system There C no private wells within 150 feet of the proposed septic system Ther is no increase in flow and/or cbange in use proposed • L 11e are no variances requested or needed. Th bottom of the proposed leaching facility will at be low less than five feet above the eimum adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor od when applicablel • the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen 1141 feet above the maximum adjusted groundwater table elevation, Please complete the following: /l ?►) Top of Ground Strtface Elevation(using GIS information) B) G.W.Elevation +the MAX. High G.W. Adjustment,���— )7 DIFFERENCE BETWEEN A and B SIGNED : Gy y[ DATE: [Sketch proposed plan of system on back). +health folder:cen . y t No. Fee Lam' ►'� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: +� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pptication for �Digogar *pgtem Construction Permit Application for a Permit to Construct( )Repair(Y )Upgrade( )Abandon( ) O Complete System LJ Individual Components Location Address or Lot No. Owner's Name Address and Tel No. Assessor's Map/Parcel /© z/r� 64 Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. ? /-� 4�1, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( �0 Other Type of Building , Ge No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow .1&2 gallons per day. Calculated daily flow !!�/1/0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /a'y,�at`,J/-;,Y p Type of S.A.S. /64,r Description of Soil: V/ �r/�f✓�' �� /9'S ��,0, 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 th Board Health. / Signed A Date Application Approved by _ Date S Application Disapproved for the following reasons Permit No. —UrV .�ZF--3 Date Issued 5_— /? — ze� TOWN OF BARNS TABLE `• LOCATION ��� SEWAGE # VILLAGE f� ASSESSOR'S MAP & LOT QZZ 1:1y% INSTALLER'S NAME&PHONE N0. �, I� >Cjj�p S jZ 7�l �39� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) . NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 5—/Z —Z51�3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist. Feet within 300 feet of leaching facility) Furnished by Feet 2x ah X,!71 SJ��,���f Nz 9 6 z o © _ 1V � 62 � 29 No. - r ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ae Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pprtcation for Migonl *pgtem Construction Permit Application for a Permit to Construct( )Repair(j/)Upgrade( )Abandon( ) ❑Complete System L'5 Individual Components Location Address or Lot No. Owner's Name Address and Tel No. Assessor's Map/Parcel �� ,' `-"" �) 7�e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /- Type of Building: ' Dwelling No.of Bedrooms '7 Lot Size sq.ft. Garbage Grinder( /�O Other Type of Building Re511,014 No.of Persons Showers( ) Cafeteria( ) Other Fixtures' Design Flow f/a gallons per day. Calculated daily flow C� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /"/Sig`).!9 R Type of S.A.S. /OZ41t1t�yZ / Description of Soil Nature of Repairs or Alterations(Answer when applicable) I`/7`<!�; ~!/Lp,�/� x5) 61iif9 � s 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 1y this Board 9f Health. Signed Date Date Application Approved by Date Application Disapproved for the following reasons Permit No. � 'Za'.3 Date Issued 5'— /2! --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 69 ZZ ley' BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( Upgraded„( ) Abandoned( )by kv,&/o//f at '7 4 1 c-y X.17,17-- C�'7`lB% has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. "2 0'-3 dated fir- 7~-Zirr"J- Installer Designer 1r! R The issuance of this permit shall/�o�t)b�e construed as a guarantee that the syste fiwill function as de/ignedC ( Date !i ! ia�l I' f Inspector )/_-i/1 0 ---�7---/—� r—�-------------------/—�,---r�—' ——--,.— tom.cw -- No. 0, — d.3 V 7_� / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ZiOpo,qar *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( �pgrade( )Abandon( ) System located at ��inY (" C'G7 fUl'�"" 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. Provided: Construction must be completed within three years of the date of this permit. /�Q Date: " Approved by 4 ` G�-.LJ� NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PETWIT (WITHOUT DESIGNED PLAINS) 1 hereby certify that the application for disposal wor!cs construction permit signed by me dated j G3I'M concerning the property located at y �7 JLC��J~ meets all of the following criteria: The failed system is conner ed to a residential dwelling only, i here are no commercial or business es associated with the dwelling. : 71 e soil is classified as CLASS 1 and the percoiation rate is less d=or equal to f minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 1-0 feet of the proposed septic system 4hereis no increase in flow and/or change in ase proposed There are no variances requested or needed. V/The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the rrimptcr /ethod when applicable] If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) (i B) G.W. Elevation +the MAX High G.W. Adjustment. -Z , = f DIFFERENCE BETWEEN A and B Z 7 SIGNED : DATE: ✓ / iJ�O1� (Sketch proposed plan of system on back]. q:health folder.cat s -4 No. ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...OF77�........... ....... . ................. .......................................................................... C)2-,7-- I I D Appliratiou for Uhipatial Works Tontitrurtion rantit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal �ystem at- .............. ....... ................ ...... . ................................ ..................................... ------ . ----- oca on �ddress " ............. . ..................................... .....kss_.:� .. ......... ......... Owner.. .... ....... ......... ..................................................... ....... ........................................... Installer Address Type of Building Size Lot............................Sq. feet U Bedrooms..___ ________________________________---------------------------------Expansion Attic (Ko Dwelling—No. of Bedro Garbage Grinder (V�43) �4 P4 Other—Type of Building C-ex?lt- �er s No of onsW?�GW...-��------- Showers (I Cafeteria (wo) &S�� P-4 Other_fixtures Tse.J.!�t............. --- ---------------------------------------------------------------------------------------------- Design Flow.....-. ..........................gallons per person per day. Total daily flow..._................. ....gallons. 1:4 Septic Tank—Liquid capacity.10&.gallons Length................ Width.............___ Diameter......-......... Depth................ Disposal Trench—No. .................... Width.t----------------- Total Length-__----..-,I----*.... Total leaching area......? ............sq. f t. Seepage Pit No---------I---------- Diameter.../0------------ Depth below inlet...6.............. Total leaching area..................sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.0et_ ................................. Datew Test Pit No. 15;W.....*..minutes per inch Depth of Test Pit__-_lam______--C)---------- Depth to ground water_-_ �_ _____.. (i, Test Pit No. 2_21.5........minutes per inch Depth of Test Pit....1_:.......... Depth to ground water J.A_0_C.%R--------- 4------------------------------------------------ Vqq 0 Description of Soil--- ......... .0 ......... .......I...........I----- OtA ----------- x U ..................................................................................................................................................................................................... ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------- ---------------------------------------------------------------------- ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTL_ 5 of the State Sanitary Code— The undersigned further agrees not to 'lace the system in I- p operation until a Certificate of Compliance has been issued by the board of health. igne ............... ------------------*------------------------------------- ---------------­­­......... Date Application Approved By---- --Ud4-,a-V-e--------------------- .... ....... Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued...................................................... Date No..............._....... FEa.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD Off- HEALTH t_, ...................OF..................... .................... ......................................... Appliration for Uiipu,ial Works Tongtrnrtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ---- .......................----------......... .............................................. _......_.....-----•-•-_.. ` ••----....----------•---•--•--................ 1L°ocation-Address or Lot No. ,r �' 1 Smart N�� , 11 �. C Lt►tiw,2�1.�1. W ......................_..i..-•-•..................•--------.__..._......_..----•----•••......--•- ----•._..._.._ C•'��.-----••-•---.-_.... ......._. ?� Owner ,�^ Adar"ess, •-•- •---------------------------------- ----------•---••-•--- ._.--..._-------.---.-----•----------•-------PQ .._........ Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms...._ .................................Expansion Attic (AC)' Garbage Grinder (A e) Other—Type of Building C.` z.! :-___.._-__- No. of persons�!:"'��:-'. ...... Showers ( 1 ) — Cafeteria (-'C) d Other fixtures ±c�b p w Z: ce" C�C' ---•...............•---------------•----------------•-----.....__......_...._.. W Design Flow........................................•._gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacitylL�v.gallons Length................ Width................ Diameter---------------- Depth................ xDisposal Trench--No..................... Width-,................. Total Length-__---------_.-•---_ Total leaching area•_____-----_.._•--•-sq. ft. Seepage Pit No--------------------- Diameter-__(............ Depth below inlet... "............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( )- `" Percolation Test Results Performed by.�Y5�''� _.._ ................................................ Date_ ................................. Test Pit No. ........minutes per inch Depth of Test Pit-----!1........_ Depth to ground water_-_V`-0_t".A____--. Test Pit No. 2.!-� ......minutes per inch Depth of Test Pit.... .:A....___.. Depth to ground water...!^4`%-' x .......... ......................... ••----......---� ------!................................................ O Description of SoiL.. "..fy �` { G,/'l f r✓c 1 f 3� t •-- •-• •-•...-- --- ------- U ................•------...-----------.............---.....----------••----•--•--......_.........-------•--•------•--........----..._.----•-------•••---......._.---•-•-•---••--•-•--•-••---------•------ W ----------------------------------------------------------------------------------------------------- ---------•--------...-----...-•-----------------••--•--•-•-----•--------------•----_.._.__._.----- 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 TITLE y g g p . y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. ,-Signed'........................................... ........................................ -----------..................... } � �� Date Application Approved By.--•- / ter* ( v .._.. a�.t ................................ ..... _'_ :..� .---•--. Date Application Disapproved for the following reasons:-----••-------------•••--•-----•----•-------•-------•-------................................................... ......--•-••--•-•---•--....._..•.....................••--..........--•-----•---.._._.._.--.._..•---•-•-••---•------•-....._...--••--•--•----••-•••-----------------------•------....................... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALT_11H_,,:_,�1 ti"Z/]7.........OF........:�+�. �� `// �rrti�irttt.� laf �nrnt�rlt�nr.� ��. THIS/IS TOICERTIFI�, That the Individual Sewage Disposal System constructed ( ' ) or Repaired ( ) by.. _... % � h sal, 1 ti r,� �t c (/ , Installer / at...........................................�'•-• ' '= =� ......•......U...... .=-......----- •--•--............----•-----•-••----.....---•----------------•-•-.........--•------- has been installed in accordance with the provisions of TITLE' j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ /,� .7...... dated--... ..._........�- . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE - ..................... Inspector_....__..... 14 THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF,HEALTH 7y ' ................................ .®F....................... ' ` � No..........7c'.............. FEE.-_.-...................... Raposa1, nrkii %onitrnrtion Vandt Permission is hereby granted ��- J,....:�fLy... '�----------•-----•---.------•---------------•--•-•------------------..------- to Construct'( ') or Repair ( ) an In(5ldttal Sewage DisposahSystem/ at No....-/�* d /l/i lc lr� 7/ ... /'� l'�l/`!Cl ---------•----------••--••----------•.... .......... ....• -_..._.. ........ -- ... ! ,.....` 11" V I ✓ Street as shown on the application for Disposal Works Construction yPe����N�-.&�.--.)��D�e��___-_.-�-_..'?.!'_........_.. ................. Board of Healthy DATE................................................................................ FORM 1255 HOSES & WARREN. INC.. PUBLISHERS Lo T 2 56 Ct j 34- r rvJ,L' S�Qr` 10 (14 to ti I ._---•_-,.--Eke �-� OF 1NALTF.NF. �Q SMITH JJR 15 F 1Z8 ,�Oc is NA- �.,. A- M A-4,4 Q t D SCALE �-- -7 c� 4g, o Or, 4�+Q N - '� • i o'P1/C 5d - p►sT.8o c 4S ,-� 1000,C-TAL !~ontC 5'Z a"a�o SE.PT1c T�tii�. � ae�aQ to m oc Bor 48 TSST Pl—,-:' QV:'a °'hitCD 1�,-7.c 3 rzao�s ti,of� 0 s 33GPO- roar �AM D !Bo-r I-a M Z. I t d /, D = l o© C, Pp 4x (nxta 6iPD -rbTAL CAW,cry oTr: UIs P SAt- 5"('bTE�A DI61'(s),)ED IQ w s-r�4 r t atiJ S 44: 1 44 Ciro' c.,A .� Zoo Z IZ AL N OTF_S •� �(• �� —- _ --- --- Al-L E L CV.. S 1-buj k) AEC M E AD.t SEA. L_S\0 c 1._ D o" LJS�; .� >",^. CJAT u►<� PS 1.1.21E �! 1p- t N - -- j— PITGtG ALL l INES A 1Vt1�.1rr�U� of L F/N6 pi�yTS'Av.Ii✓ruL�Y r�--I—�-\/ '1���1 - �, NN�I - ll ),' � m�— � \ --\ i � `�E-i,\' rrN�JI A.N►1L�G�1C.A�D Pv1A i�EPD�DEE+EPgC fWcTToaH�SE/�EInAHJ`QAsT. LZQ4,L+ 1-1 C1��ETSy HS�E�bE csST 1210" doe_ X-d6OuT:,E_E,ESS,cr\Y'i•r,`A>ti�TS1O�E NPE /S�AOC ALL ISEPTAC TA"Ksr P .re1t3JTICJ fix, A"Mf�� ►tPi)2d' 000 cL 4 -n 3 O �' MITI=--- I V F_ E Au- v.JSvIra3LE MATEZ%A.L. 5c:0.2A L�T1t- L 1 EiEL.EVAT10 -AS of L_E,NCF41.� FrS F•�Cl A C-IxD�S of i<7 Iwo ebCr�l T1-A C L.a.y FVc :T _ TV}E "u%T® UC_ cc) fo �� �f ® , Zo• .�x"�..-- � __,,,, to" �_ I `! 1 J � �--- v►s L,E5� OTNEt?. :I S E t.1oT�U, A L->` uY ST�r� �` © I G = SA.JIT_A, 0 : ^ C) O COh'APO+JIE�s15 s+�eat� �E {.,;to.� cc� 1►J (�' 4C.0 CY2 is V.,'ITH r 1 T L_E � r F r1►E ZTAT E s f lTr��y c ow A,"C) ,sr J-j Lxlc.e.X. Z_)L_4`c, TYPICAL. DIST2.tbVT•f0rJ E50x- I O co 0 C', �� O ��' - � f } � I � v v1N I G N f.A AY A p►�'L-�/. ►J OT T@1 §GALE 1_ _ — .. - — - T _j -- -- �oTE �i.�Te���T,nj r...t+, Icy .!_ T PKi►` I ICAO G�►�- SEPTtC, -r^"*S _ T�vPi A _ t4�—�i.iC _..._ {P► If QM.-t VA T/O N P/75 DY A. 1E K,CMj vACoC_P.ST ► CPT _vl) 5CAL.E H1UT TG XI.L E - �� �Q UA L 1..CATTc.: T�•,J11.S fZF c,.L Ft�Cc:E G T..E'!)..G-r ovT OF.e CO[.A T/O AV 0_A 7Z' wITN EL..E�CT�'IL wE.t�-a w,2t wry 24 - AIL` EMBEoOED sTseL eozD'S ..I tJOTl%AUGE yav-rlc Tr�jc ^A Lrw,CWt C,.. r7 rg ' 80,4�[O aF fi�A L TH �i✓� �OT•,'Gr✓f. COa1C. !6 4000 PS,I T$"�T `+O �S.E Q�V�LT VP TO 1?"nitl{C'S c 8•E LGVLJ F IrJ i'yN G M2"'A i7 Zf /L.CJ V,A a w /�C r,, 'PL -(Ory F04J.y DAT10,.4 A9AM �'Filr r?i12 - r \ ):lh115F4 ro[I•DIE F INISt 6J'tI-.L'7E_- F 1I.11SN' C��1L ALA GVLSC.- �Frj1 ISH G IL._DC '� cvr IWI-kKa •6'x, ai.<¢`L�L�, = LEALCHI►1 N` G vI ( :: _ cItF�LL , �-5 3� P1°isro+JE W� ! eelk4Fo c n tsal< p 00 v•s � A O m �®TAM Prr 3 - L. ® ® ELEV l T— I i ►6E Lev STABL E L.G) Y 7- /8 TyP i C A L 5 E y1,aGE S �z E M PVCI't�� g -----� LJo'T T�sc.o..1 � L\ 4 .a A4. 4 0 L4 LEGEA/D -:� = — Er�sT OorvTout PROP05ED D\(/GLLI KlG LOCATION _. _. .. _ EYI z7'• i_.,qT _,____ DES/GN cel7-eel,4 PatOib�Co CavTd!/.0 o _ - - �HOFM PROPOSED S WAGE DISPOSAL SYsT�-M Nvn.�Aee OF BEo.¢00'W 5 4 " EAi�r �°ar Env �P` Ass n CAC� oo�4 700�; 000 ,�/OT E[-F�/• ♦ i� ►�IORMAN �+ �z� .L.G T L� .�il�/�i.�l...C•A�:.�� T.+�/h�' VET fie_.2w o45e A4 Y _..'�'.�� PF.PICXA>r Tex " GROSSMAN GALLGWS oesE,c ��r Pr. pNo 111;3 O A ?°'J�T MA SS . f.'o Gc//r1/6 AX64 br I Lam,,c�iNG A tEA o�ror� w _b !$�FF� -f N IL PPOPOSED LEACHINc'. PIT FSSLLk. ,QQPL{GAA1T �i.[Gt1fIG�2: r TtiEd GGNS'7 4111 G=A?44SES1)XIII 24 42QE4 1' Re AD" "P;i .224 MOL4Y ADIA1T 10D. NORMAN Gs GROSSMAN _ S/27i�tllALL A.@EA �w•:r tLt `���'S ' 377 G �V• ko .- `^ I� SCALE: DATE: $MEET TQTRL 42,77 G IP UR DRAWN 9Y C NKD BY: APPD SY PLAN NO.