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HomeMy WebLinkAbout0059 COTUIT COVE ROAD - Health 59 COTUIT COVE ROAD, COTUIT - -- A= 005 040 - -- - i i 0 No. Fee om i THE COMMONWEALTH OF MASSACHUSETTS Entered in comp er:_�� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplitation for Misposaf 6pstrin Construction 30ermit Application for a Permit to Construct( ) Repair()d Upgrade( ) Abandon( ) ❑Complete System XIndividual Components Location Address or Lot No. i Owner's Name• ddress and Tel.No. 59 Cc��v T ���� R� ,A , RKk4AZD S KA,it{L4SffTr1 C?®i.ux4l� Assessor'sMap/Parcel 605 16(io 00rL_)41 Vol0p)( 104co Cv_rvcr Installer's Name,Address,and Tel.No. j —(�71_�!,Z1 Designer's Name,Address,and Tel.No. dAPc D& El.��c14� 7' 16D 01 A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _T— Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo e p Signe Date j ,10 Application Approved by Date Application Disapproved by _ Date for the following reasons Permit No. U Date Issued , i` .'_.. _'. .. •'-" ;.--.,--. .. r, „+.n..-, _,._• ..T, r .�.__.._..*.�'-s',''�-"`.7` ' y..'�,ri�. �A•�.,,,�;,�,�.;"N..;,�.i6T'tr�`+t No. te1 �J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in compu er: ' Yes PUBLIC HEALTH DIVISION -TOWN.OF BARNSTABLE, MASSACHUSETTS 21pplication for -Misposal *pstrm Construction 3permit Application fora Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 59 C657 0 1"[' G,OVE, R,Tj Owner's Name,Address,and Tel.No. Assessor's.Map/Parcel d(� 6qo Q(XL-)r p Oo�'1 � <e�u cr Installer's Name,Address,and Te.No. 57OS-410-R271 Designer's Name,Address,and Tel.No. Type of Building: r Dwelling No.of ge`drooms Lot Size sq.ft. Garbage Grinder Other Type of Building ]}'1 j�,, No.of Persons Showers( ) Cafeteria(!) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title 8 Size of Septic Tank r Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) gJSrA4_ __ Wes0 4QTL6_-r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board 9fHealth. _ p Signe! ' Date Application Approved by Date Application Disapproved by Date p : 4, for'the following reasons Permit.No.DQY 17 "' / 01-'�t— Date Issued "1 J(© 11 9 ` THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS = - - Certificate of Compliance , THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by C PMU t D C 60. Mr o at S9 (MO <,OUE J) C'TO( T+ has been constructed in accordance J with the provisions of Title 5 and the for Disposal System Construction Permit No.: �p � ✓Jcs�.dated Installer Gi*4➢r-wcP& &J J'�'. .b� R� Designer '�A � #bedrooms e fi\) y 4. Approved design flow . / ,/L and The issuance of thhis permit shall not be construed as a guarantee that the system will,_fu c .finn A designe Date --1 ! 4} Inspector04 No.. �� 1 .�.. 1 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal 6pstrm Construction 3pPrmit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon(_ ) System located at 59 O b T u a Q O tJ& Ph and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. ' Date �!' `� Approved by �-- -✓ i . Gb5- 0q0 Commonwealth of Massachusetts Title 5 Official Inspection Form rj-��11 it Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. 59 Cotuit Cove V Property Address s Kathy Rowan Owner Cwner's Name Imo: information is Cotuit required for every MA 02635 4-11-1;�9' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, �C?:", �y s use only the tab James D. Sears = : JA M ES N key to move your Name of Inspector =0 SEARS cursor-do not Ca evvide Enterprises *'. use the return key. Company Name t RTIP\ O �• 153 Commercial Street IN gpti�'�\�\``�� 'f� Company Address VQ tlnn Mashpee' MA 02649 Cltyfrown State Zip Code 7 508-477-8877 S1623' Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4.. ❑ Fails 4-12-19 �,pectoft'ssigna�ire Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditlons of use. r5insp.doe-rev.712612018 Title 5 official Inspection Form:Subsurface sewage Disposat system•Page 1 of 16 I• abed, xed dH Lt,:81, 6602 tt ud`d Commonwealth of Massachusetts P Title 5 Official Inspection Form nl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Cotuit Cove vv��- e Property Address Kathy Rowan Owner Owners Name information is C01ult required for every MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary. Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and Pit 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will,pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2078 Title 5 Official Inspecdon Form:Subsurface Sewage Disposal system•Page 2 of is ,r 2 a5ed xeJ dH &S 1, 6 60Z 176 add Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r; 59 Cotuit Cove Property Address Kathy Rowan Owner Owners Name Information is required for every Cotuit MA 02635 4-11-19 page, CitylTown State Zip Code Date of Inspection C. Inspection Summary (Cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box, System will pass Inspection if(with approval of Hoard of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s), The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 £ a5ed xed dH LV:2 6 61,02 171, JdV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 97P 59 Cotuit Cove Property Address Kathy Rowan Owner Owners Name information is required for every COtuit MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS Is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance; `*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliforrn 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to ovedoaded,or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface wafers due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title B Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 abed xeJ dH &81. 61,02 '6 JdV Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy Rowan Owner Owner's Name Information is required for every COtUIt MA 02635 4-11-19 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in Is less than 6"below invert or available volume is less than 'V2 day flow '7— ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The. system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system Is within 400 feet of a surface drinking water supply El ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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 t5insp.doc rev.712612DI8 Tllle 5 Officiel Inspection Form:Subsurlace Sewage Disposal System-Page 5 of 18 g abed xed dH Ltpi81. 61,02 t76 JdV Commonwealth of Massachusetts P Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy.Rowan Owner Owners Name information is Cotuit required for every MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No ❑ ® _ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information.For example,a plan at the Board of Health. � ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5inW.doc•rev,7i2W21116 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System Page 6 of 18 9 abed YPJ dH Lb:86 61.02 t 1, Jdy Commonwealth of Massachusetts U � Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 59 Cotuit Cove VProperty Address Kathy.Rowan Owner Owner's Name information is required for every Cotuit MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 440 Description: 1500 Gal.Tank D Box and pit. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2017-27.00OGals 2018-69,OOOGal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/2612018 Title 5 OfBdal Inspection Form:Subsafaos Sewage Disposal System-Page 7 of 1B a5ed xej dH Lb:81, 61.0Z b6 JdV I Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy Rowan Owner Owner's Name information is required for every COtul2 MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑_ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancyluse: Date Other(describe below): 3. Pumping Records: , Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® M If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: tSlnsp.doc•rev.7!282018 Title 5 Official inspection form:Subsurface Sewage Disposal System•Page 8 of 1e 9 a5ed xed dH Lt7:86 61.02 V6 add f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy.Rowan Owner Owner's Name information is COtUt required for ev I MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspectlon D. System Information (cant.) 4. 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/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1981 Permit # 81 - 135. Were sewage odors detected when arriving at the site? ❑ Yes ® 'No 5. Building Sewer(locate on site plan): Depth below grade` f 2ee 9 Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. t5insp.doc rev.712612DI8 Title 5 Official mspeclion Form:Subsurface Sewage Disposal System-Page 8 of 18 6 a5ed xed dH 8t,:8I• 660Z t,� JdV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy Rowan Owner Owner's Name " Information is required for every Cotuit MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 19"feel Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: . V. Distance from top of sludge to bottom of outlet tee or baffle 29 011 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Note: Inlet cover under large flat stone patio. Tank and outlet cover at 19" below grade. In and outlet tee's. No sign of leakage or over loading. tShsp.doc•rev.7,2612018 Title S Ofriciel Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 0 6 abed XPJ dH W81, 61.0Z b l• Jdy f Commonwealth of Massachusetts Title 5 Official Inspection Form t' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy.Rowan Owner Owner's Name information is required for every Cotuit MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions; Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.). 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions. Capacity; • gallons Design Flow; gallons per day t8lnsp.doc•rev.7262018 Title 5 Official Inspecion Form:Subsurface Sewage Disposal System-Page 11 of 18 6 abed xej dH 8jV:81. 61.0Z V1• JdV Commonwealth of Massachusetts VVTitle 5 Official Inspection Form X Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy_Rowan Owner Owners Name information is required for every COtUIt MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): - Depth of liquid level above outlet invert 0 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.): D Box is plastic 14"W'-26" below grade w/one line out. Box is clean and solid w/no sign of over loading. t5lnsp,doe-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Z6 a5ed Xed dH W86 660Z t76 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 59 Cotuit Cove Property Address Kathy Rowan Owner Owner's Name Inform required re Cotuit MA 02635 4-11-19 required far every page, City/Town State Zip Code Date of InspectiDn D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soll Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located, explain why: i Type: leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc•rev.7126/2018 Title 5 Offidal Inspection Form:Subsurlaoe Sewage Disposal System-Page 13 of 18 £6 abed YU dH W8 6 61.0Z V 6 Jdy Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy Rowan Owner Owner's Name inform required for Cotuit MA 02635 4-11-19 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is a 1000 Gal. Precast Pit. Pit and cover at 25" below grade, Level in pit at 30" below inlet. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doc rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 16 a5ed xed dH 6t,:81, 6 We b 6 JdV Commonwealth of Massachusetts Title 5 Official Inspection Form 14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Cotu it Cove Property Address Kathy Rowan Owner Owners Name information is required For every Cotuit MA 02635 4-11-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont,) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tSmap.doc•rev.7;2MOIS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 5 6 a5ed xed dH W9� 6 602 t,6 add 7 Commonwealth of Massachusetts Title 5 Official Inspection Form 'a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy Rowan Owner Owner's Name information is required for every Cotuit MA 02635 4-11-19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 5re/Vi- v PA t '3 13,l : 36 �3 = 31" 13 - t5insp.doc-rev,7@612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 g l, a5ed xed dH 6b:g t 6 602 V 6 add I Commonwealth of Massachusetts p Title 5 Official Inspection Form �ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Cotuit Cove Property Address Kathy Rowan Owner Owner's Name information is required for every Cotuit MA 02635 4-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells a� Estimated depth t high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1981 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H.on Design plan 1981 12' no G.W.. Bottom pit at 8'below grade. Bottom of pit at 4'above T.H. Depth. Before Filing this Inspection Report, please see Report Completeness Checklist on next page, t5insp.doc-rev,74612018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 16 L 6 a5ed xed dH 6b:8 6 61,2 t,6 Jdf Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -" p 59 Cotuit Cove Property Address Kathy Rowan Owner Owner's Name , information is required for every Cotuit MA 02635 4-11-19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form Inclusive of: ® A. Inspector Information:Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3 or 5 completed as appropriate p pp opriate 4(Failure Criteria)and 6 (Checklist)completed ® D, System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included GROE 7N N0 t5lnsp.doe-rev.7!26r2018 Title 5 Official Inspeclion Form:Subsurface Sewage Oisposel System Page la of 1a g abed xeJ dH 6t,:R b 6 60Z V 6 JdV �-� COM. NIONWEALTI-I OF MASSACOUSET S EXECUTIVE OFFICE OF ENVIRONMENTAL. >1� UF]'ARTMFNT OF ENVIRONMENTAL P C TEST] 0\1: MNIrR SfRFFI. BOSTON. NIA 02109 hl-2-9 10 CT 9 wll.l.In�ar ��rl.h �' !Dvcc�xr OONernu! 350 MAIN STREET 4 �� Sccrclar, r WEST YARMOUTH, MA Vli)F1 S i Rl M ARGLf)PAI II.Ct:I.I.1K Cl 508-775-2800 ` Cnrnmicci�nn l.I Gnvcmnr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 005 PAR 040 PROPERTY ADDRESS: 59 COTUIT COVE ROAD,COTUIT ADDRESS OF OWNER: DATE OF INSPECTION: OCTOBER 20, 1998 GREGORY LOUGH NAME OF INSPECTOR: JAMES D.SEARS I am a DEP approved system inspector pursuant to Section.15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: 25�� DATE: OCTOBER 21, 1998 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: SITE OVER ALL PASSES, INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. B SYSTEM CONDITIONALLY PASSES: N/A 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 b the Board of Health,will pass. Indicate yes, no,or not determined(Y, N,or NO). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal;unless the.owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Page 1 of 10 (Revised 04/215/97) DEP on the World,Wide Web:http://www.magnet.state.ma.un/d r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20,1998 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NIA Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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 and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20,1998 D]SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: NIA I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility'or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded 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 Yz 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 64/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20,1998 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)) (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20,1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g.p.d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 2 Garbage grinder(yes or no): NO Laundry connected to system(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): 1997 83,000/1998 61,000 Sump Pump(yes or no): NO COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) NO If yes, volume pumped: Gallons Reason for pumping TYPE OF SYSTEM X 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM 1981, PERMIT#81-135 D-BOX PERMIT#98-680 Sewage odors detected when arriving at the site:(yes or no) NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20, 1998 BUILDING SEWER: NIA (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK:_X (Locate on site plan) Depth below grade: 12 Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 1° Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 27" How dimensions were determined AS BUILT&TAPE Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL OUTLET BAFFLE,INLET TEE INLET COVER UNDER DECK.TANK AND COVERS 12"BELOW GRADE. GREASE TRAP: N/A (locate on site plan) i 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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20,1998 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ Concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Design flow: gallons/day Alarm level: Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,.etc.) DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: 26" Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) D-BOX IS NEW 9"X 15",ONE IN,ONE OUT,CLEAN AND LEVEL PUMP CHAMBER: N/A (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.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20, 1998 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number: 1 leaching chambers, number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number, alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) ONE 1,000 GALLON PRE CAST PIT,COVER AND PIT 26"BELOW GRADE, HIGH WATER MARK 2 Yz' FROM BOTTOM. CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure„level of ponding,condition of vegetation,etc.) PRIVY: N/A (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100(locate where public water supply comes into house) O 5 � y� N3 �, 0 36 (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 COTUIT COVE ROAD,COTUIT Owner: LOUGH,GREGORY Date of Inspection: OCTOBER 20,1 998 Depth to no groundwater 12 feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE:NO WATER AT 12',TAKEN OF PLAN. TOWN OF BARNSTABLE lL LOCATION .fq raT,117 00rs£ IRJ SEWAGE # c .- VILLAGE Ca L l T ^ ASSESSOR'S MAP & LOT yos-a Y- i INSTALLER'S NAME&PHONE NO. /'� � ('AIV 7 s^ SEPTIC TANK CAPACITY 4 LEACHING FACILITY: (type) (size) 'p NO.OF BEDROOMS OX— 0 3 4 LC7�fl BUILDER OR OWNER f PERMTTDATE: /O 0T COMPLIANCE DATE: io"-"))' Separation Distance'Between the: I 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 jEdge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i s a i i t 1 0 COT 751`1 R� e� \A- LOT 39 110 ----------------- - ctij� 0 0 <i f'e�}If - 2nd STORY S DECK �6.'I' 5�. �A 3,21p,, � . Op LOT 40 ao i3o6q-75' RES. ZONE.• 'RF" This MORTGAGE INS P ECTIO N Plan is For FLOOD ZONE- "C" Bank Use Only TOWN: - COT-U-IT_ _ REGISTRY OWNER: ✓OHN P. & E=AEETFI WALLACE NOONAN. JR DEED REF: 31Z4Z2420 •_ = _BUYER: PAUL G�fING & F. ADELLE DELIS DATE: �17�2_ _ PLAN REF: 22 39 _ _SCALE:I"= 40___ .FT. I HEREBY CERTIFY TO FLYW00E MORTGAGE —CO.----,- ----- _____ __ ___ ____THAT THE BUILDING ���H OF arasf�'+ YANKEE SURVEY SHOWN ON, THIS PLAN IS LOCATED ON THE GROUND AS CONSULTANTS SHOWN AND THAT ITS POSITION DOES _ __ CONFORM FA. a� TO THE ZONING LAW SETBACK .REQUIREMENTS OF THE � MER THEW 143 ROUTE 149 TOWN OF _BARNSTABLE_. _ ------_AND THAT .0 No. 32098 a .MARSTONS MILLS, MA. 02648 . IT DOES__NOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD ��-�. �fC1STER`�� �``�� TEL- 428-0055 . AREA AS SHOWN ON THE H.U.D. MAP. DATEDNg �o.S�Q Cora-munit —Panel ,250001 0021 D .;;. F Fa FAX 420-5553 _ _____ THIS PEM ;;NOT 'MADE FROM AN. TRUMENT BJS �,=PAUC A. .d�ITH PIS' ` SURVEY MOT TO BE.USED :FOR FENCES, ETC: 9.218 •. TOWN OF BARNSTABLE vF � • �P� IFTiON` ,—f Oft L�© R SEWAGE aR.LAGE ' -��r l 1 ASSESSOR'S MAP& LOT 00�-U y® �INSTALLER'S:NAME&PHONE NO. /� �� ('��iC© ����� -SEPTIC-TANK.CAPACTTY -LEAC,KNG FACII.TTY: (type) (size) NO OFBEDROOMS •'BUILDER OR-OWNER' PERMPTDATE �d .l-�� 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- �� �3� � t �/, e/3 0 ' �G' � ��, �F�� q . No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: zl Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Dioaal *p5tem Cou!5tructiou Permit Application for a Permit to Construct( )Repair( 'j Upgrade( )Abandon( ) ❑Complete System JKIndividual Components Location Address or Lot No.37Y C oTv f- 1?piv r Ai_b Owner's Name,Address and Tel.No. 4W- Assessor's Map/Parcel C 07-1/er /,ay e-11 �RE�fY .--- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 50 ��/A- v YV Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building / trd S r 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 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 issu d by this Board of Healt Signed Date Application Approved by _ r�'C Date /b —Z l— 9 '� Application Disapproved for the following reasons _ate�--- Fee ✓y• / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V ".�� ; •.,�� Yes PUBLIC HEALTH DIVISION.: TOWN OF BARNSTABLES MASSACHUSETTS ZIppficatiou for Dfigponl *pgtem (Construction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) O Complete System [Individual Components Location Address or Lot No..rf C07_a,7" a W f R 3 Owner's Name,Address and Tel.No. Assessor's Map/Parcel C ;T .4®U C-# 4:tfZ��Y o 0-f-D o 33I C®7L,r ravz .a3 to67ui7"- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -Arag, 4v-yz Type of Building: Dwelling No.of Bedrooms_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building a_5= 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 Nature of Repairs or Alterations(Answer when applicable) 76 Q 40,Y /d°f/O/rg C IA fA-7 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 Date Application Approved by A Z Date 16 -7/- 9 P Application Disapproved for the following reasons Permit No. 9 67 IFO -Date Issued' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgrade`( ) Abandoned( )by iV co ! :C,9 5 7- 4cr •Y/fif at Co7u,T (!!,gu r has been constructed in accordance with the provisions of Title 5 and the •r Disposal System Construction Permit No. dated /- Installer Designer The issua ce of this permit shall not be construed as a guarantee that the system ill funct�i a signed. Date /{��?_ /- 9 Inspectors No. ------------Fee _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 'i5po5af *pgtem (Construction permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at $ '�/ C�lea.�9"` C'9 U£ if)t C'a�yl7T and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to r 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 a t. Date: �d 2 /-5 Approved by (- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO.N .FORM �. Address. of property' �y s Owner's name'. .Date of IrfspeGtion PART A . CHECKLIST Check ,.if .the :fo.11owing ,have:: been .done: _X Pumping information was requested of the. owner, occupant, and, Board .of Health. -None of the system components have been pumped for at least two weeks and 'the system has been receiving. normal flow rates during that period. Large: volumes of water have not -been introduced into the system. rece.ntly or as part of this inspection. i.; A As .�built plans. have been obtained and examined. . Note if they are not available with N/A.. _ -The facility" or .dwelling was inspected for signs of sewage back-up. X The site 'was inspected for signs of breakout. All system components, excluding. the • SAS, have been located on the site.. The septic tank manholes were uncovered, opened, and the interior of the .septic tank was inspected for condition of baffles or tees, -material of construction, dimensions, depth of.. liquid, depth of sludge, - depth of scum. 7t the size and location of the SAS on the site. has been determined based on...existng .information 'or approximated by non-intrusive methods_. facility-owner (and occupants, - if different .from owner), were. provided-.:With.. information":on�.-the .proper maintenance .:of. SSDS.' ` .sUBSURFACE. SEWAGE DISPOSAL SYSTEM -INSPECTION FORM _. PART B SYSTEM INF0RMATIQN .. '.:FLOW".CONDI' 'ION�,• If residential _ number of bedrooms ` ... �5 number of current residents . garbage grinder, , yes. or. 'no ` s l.au.ndry connected 'to system; yes' or '`no tom: seasonal use, yes or no If nonresidential , calculated 'flow: Water meter readings, if . available: Last. date of .occupancy'. GENERAL INFORMATION Pumping records and source of information: i«� > c S 7 = .System pumped as .part -of inspection, yes or no if yes, volume pumped Reason for pumping: Type of system Septic tank/distribution box/soil absorption system. - Single cesspool Overflow cesspool Privy shared;.system ' fye's..,•o.r...* : (,if des, attach previdus inspection : records, . if any) ° Other (explain) APProximate age of all cramponents.,' Date :.insal7ed' if informati.ori: J. known. Source o€ . •Krv1 - `. ' `'' '• .lam w.r� i t�5`• -1�' Sei�a9. :odors detected. when .arriving at t2�e- site, yes or no, SUBSURFACE Sk1WX .E''.DISPOSAL M SYSTE INSPECTIW;; FORM:- . . � • .. PART B .. .: : • l SY8TEM INFORMATION..continued SEPTIC TANK:. . (locate. on ste..plan) depth. below grade: t3 5 .6. At.. material o:f :.construction: LX_concr.ete metal FRP other:(explain) 7. dimensions Z sludge depth b7o distance from top of sludge to bottom of outlet tee or baffle- scum- thickness 9,5� 'distance - from top of'. .scum, to. top :of outlet:..tee..or, baffle . distance from bottom of scum to bottom of outlet tee or baffle Com Tents (recommendat ion .,for p.umping, . cond:ition of inlet and outlet .tees or baffles, . depth of liquid, level in relation ,to outlet invert,' -structural integrity, evidence of leaka:ge,. .recommendation' s for' repairs-, etc. ) y" .ice' [ti cLu CvI Y I -e `� }.. Cic• a k. v �cL S 4C, Sr Vic, VLC_ r vic. &VsAe,,✓t•' DISTRIBUTION BOX: X (locate on site plan) depth of liquid level above outlet invert Comments.: (note if-. level and distribution is equal, evidence of solids carryover, ..evidence of .leakage: into or'-out of bo_ x, .recommendation for repairs.,. etc. ) Ini on � Ir �ivc. fl:� c [�i�}vt�.4iU'1 ✓ti � c ,x�l'i�c .. ,nc F.v �r�.-icy. it�.lva �c,��/ .�;�.ar �- v►o. ,fic^:wYw�-i�c.�i..vS �.�� .,r�rx�if. PUb1P...CHAMBER:. N� locate ,o:n- 'site:'plan) A pumps: . in working. cirder., yes. or no Co:mmeftts (iaot:e : cond ti.on of. .pump :chamber; conditions of. pumps :-and :appurtenances, recommendations f or._ maintenance: or repairs, etc•..) SUBSUPFAGE".: EWAGE `tISPOSAL.'SY,STEM: ZNSPE'TION FORM PART S : . SYSTEM INFORMATION contiaued SOIL ABSORPTION SYSTEM .(SAS.),.; X {1o.cate .on • site. plan, if :possibl>e.; excavation not required, but: may 'be approximated by non-intrusive methods) . If.:. not determined to be.,present,.'. explains Type . leaching pits and- number. 1 �[:ir�rliyti aT Gs vil•� (� i leaching chambers and. number. -- ' leaching galleries -and -number . leaching trenches, number, length . . leaching fields, numb.er, .dimensions . overflow- cesspool; number Comments: (note. condition.: of .soil, signs of hydraulic €ailu.re, level of 'ponding, condition of vegetation; recommendatio s for maintenance .or repairs,etc: ) 77 CESSPOOLS (.locate on site plan) number and .configuration NA depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of :construction indication of groundwater ' inf--low (cesspool must be pumped as. pant of i.nspection.) . Comments:. (rigte condition• of', soil; signs .of hydraulic .failu-re.,. level of'ponding'; c©riciition .:of vegetation, : recoinirendat.ions.' for. ma-intencinc-e ..or , rep airs PRIVY: .. • .. (locate: on site .-:plan) mater:ia.ls: of construction. .dimensions depth of solids • Comments; (note -condition of soil,: signs of hydraulic failure, - level of .ponding condition of vegetation; recommendations for maintenance or :repairs, etc. ):. _ SUBSURFACE.-SEWAGE DZS.P69AL .B.YBT$M. 'I'NSPECTIQN PART .0 FAILURE CRITERIA . .. Indicate, yes, .no, or-.not .dete.rmineci .jY,...N., :.or ND)':. . Describe basis of determ nat.i.on in: a1] . instances If "not deter-inilied'; explain _why not) .' Backup of sewage into facility? IVo Discharge .or .ponding of effluent .to the . sQrfa&e of the ground or, surface .:waters? . Static liq uid level in the distribution box above outlet invert? Liquid depth in :cesspool <6" below flow? invert or available wolume< 1/2 da `Required pumping4 times or mor e in the last year?... number .Of: times pumped �►e Septic tank is metal? cracked? structurally unsound? substantial . infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool' or privy: _ below the high groundwater elevation?. tom;, within 50 feet of a surface water? _ within ..100 feet of a surface water supply or tributary y to .a surf water su PP Y'1 ace • faith n `a Zone 3 .of. a .pubi-iG well? ` within 50 feet of a bordering..-vegetated wetland or. salt marsh ., jcesspogls and. privies and y, 'not•.the . SAS).'? L}, within 50 feet of a. private water:supply. we112 c _ .less than . 100 feet but greater than 50 feet .from :a private` .water 'supply well with no -acceptable water quality :analysis?. If the- has: been a .nalyzed .to be acceptable, attach. copy of well water analysis for coliform bacteria; volatile organic compounds., ammonia nitrogen and nitrate nitrogen. SUBSURFACE' SEWAGE -DIS•POSAL' SYSTEM: INSPECTION FORM PART' B. SYSTEM . INFORMATION .continued SKETCH- .OF .SEWAGE DISPOSAL SYSTEM': -include ties..to. at least. two permanent . references. landmarks .or.. benchmarks. locate ,all wells within .100*1' I J, I. 1 Y"�alI :;: I`ev DEPTH. TO GROUNDWATER` , 1 Z. .. . depth `to groundwater method of. :determination or. approximation: . .. -a ' ' wit 'w � - , } '-�• is�«�1 �`� ��:...<�_We�V,S Cz� r��y�;c�j�,�f." • T ��``. �.i.M t�' � 'l��:L. ':.`_�1. `-�l/{'. .I�,.al '�� r_s.4V vt�-.�, ` (_•t 't ,N tc_,1 IZ L,fw .•ia` L :'1 .z i:� �r .��1 j r •( �t�F ��Y i� •t-JvcM.:'yl c��cW 14` •f, -.c I s i-i ' `.fi J'.i'CY dill C�[vs-7�t %J itY[\!•f'° �1: �c'4 �i'�:` •cylc•f�'1 � - J.,�'L�•.' .��� ckC.' -`• IN : - 13 SUBSURFACE SEWAGE. DISPOSAL SYSTEX hNSPECTION .FORZvi.:. ;. PART D CERTIFICATION r� C . Name of Intspe.ctor.: S K :� �. G 2 � ,���.• Company Name. Company Addxess 2-3 Yvvv_> Certification Statement I certify that I have ,personally inspected -the' nspected the sewage disposal system at this .address and that- the information -reported-.is true, ..accurate and. complete .as -of. .the time-of inspection.- - The ,inspection Was performed and any recommendations regarding upgrade, maintenance and repair are consistent with- my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: I :have not found ariy' information which. indicates that the system .fails to adequately protect public health or. the environment as defined in 310 CMR 1.5. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that th." system fails to -protect public health ..arid the environment as defined• in 31.0 CMR 15. 3.03 . The basis for this determination is provided in .the FAILURE CRITERIA section of this form. Inspector's Signature Date �.l��! ZZ Original to system owner Copies to: • Buyer (if app3icable)'. .4pptov ng­Atitharity• : . . ; 350 Main St., West Yarmouth, MA 02673 : . . PORD*?ER�D7ATE�� PHONE.NUMBER ` A.M.-DATE P.ROMI$ED P.M.L. ACCOUNT NUMBER : LOCAti a � .. �. OFF !G : CAPE. .. - M -T W T F ••S . . / l✓ - " — 'Dlr'tECT10N$.'SPECIAL INSTRUCT•=hS . J j x STREET.• �•C�' U�r F1(i L�c�' .OFF 7 ^ . TOWN 13I I t TO.._ __ , STRcET_ : 'PERMIT# CITY 'SIP. =G CA V M'C. VISA Authored by GAL UNIT;RATE " PUMPING -,RESIDENTIAL S.a� ��' JSVI j PUMPING _ COMMERCIAL ADDITIONAL TANKS - PITS I ! ADDITIONAL HOSE. i ! I DIGGING"TO LOCATE t" _""EAR'DRAIN..LINE HAND MACHN VALUATION ='SEPTIC SYSTEM ✓O�'ERS.— FRAMES j WATER'BLASTI.NG. I ; I TUCK & DRIVER STANDBY PRIORITY PUMPING TIME FINISHED 1 �•�; OPERATOR I DATES TRAVEL ABOVE LINE TOTAL TIME TIME sTALINERTED TIME / 6cLOW LABOR.. NOT RECpONSIBLE rbA nNY DAMAGE TO PROPERTY he.ret�y accept above re'rfcrnrie5l service and'lebor•ss beln'co'sStlstactory MASS.SAL•Ej'7AX.5%..' , - .-• anG acknowledge tho equtpmeni•has been le'ft.in good condition., I :erect at 7/-%per morith I18%per annum'will bp charged or9 accounts . .�ier 30 days from pilling d2te. - •.•PLEASE PAY. .'. . cu'�orL_la X :� i /h(� :. THI,'s OCl� TA�,' � .7A " L L.O .CAT-10N.- ` C .. : i S.EWAGE PERMIT . M0. ncu Y` VILLAGE , C1�..ST.A LL:ER' NAME . f!.... ' ADD.R�ES.S Pr • �.: ,.OR W.N ER :.: DATE PERMIT ISSUED OAT COMPL.tANCE . ISSUED . t e . 50 — _ 0t.. .` s �035.1� 6 101 99 �r \Ar LOT 39 „----------------- X 2i,2d STORY Uv'� DECK -61 I6s0p Sly -LOT—40 - M „ Plan is For RES. ZONE- RF This MORTGAGE INSPECTION FLOOD ZONE- "c" Bank Use Only TOWN: COTII T �' REGISTRY OWNER`. J0 N P. . , ELIZABP WALLACE NOONAN JR. DEED , 1 980 —BUYER: PAUL GKIN _&=F. "ADELLF DANIU DATE: Z1712_ - PLAN REF: 22 39_ -_ _ _SCALE:1"— 40___FT. I HEREBY CERTIFY TO �'LYMQUTK-MQRTCt9GE CQ____ OF ss YANKEE SURVEY ___ _ ____ _ ___ THAT THE BUILDING ��N 4a SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS o�� PAUL � CONSULTANTS -SHOWN AND THAT ITS POSITION DOES ___— CONFORM A. TO THE ZONING LAW SETBACK REQUIREMENTS OF THE 8 -MERITHEW . 143 ROUTE 149 TOWN OF BARNSTABLE-------------AND THAT .o No. 32098 MARSTONS MILLS, MA: 02648 IT DOES NO_T .LIE WITHIN THE SPECIAL FLOOD HAZARD 9��Fs �fGISTER`�� e��io TEL: ' 428-0055 . 'AREA AS SHOWN- ON THE. H.U:D. fi2A.P DATED_ Z 9_2__ sioya� A�yosJ FAX: 420=5553 0»rnunity=.P.ane1 `2500QL 0021. D .. fmS PLANT .MADE FROM AN TRU1iENT ^- ^-^ LOCATION i`�3 SEWAGE PERMIT NO. � TQv VIL ACE INSTALLER'S NAME i ADDRESS LK1y I UILQE OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED N� �y «'5 To�f a- � r i TOwN Ng� j No.-•--••-•--•..3s� Ficis ............... THE COMMONWEALTH OF MASSACHUSETTS T BOARD 4 YRD OF HEALTH YL ■ H i . . ...........................................0� ......OF...................... ... 2 J�vpp tr a#tou for Uhipoii al Workii TouDtrurfivit ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: C©fUt W � r—'•`Lo�ati`on...&.�ss� A)�� -•-•- ----�-.. f 3 or C�of---lJ l - ».._.. .-.......-- wner Address W Lt. 1 C..r S.c•o ✓ v.e.S. -- ........................... .•-----------------------•---------------•--------•---....------_....:__...........------._....... Installer Address QType of Building Size Lot__QJ..3_�n.Sq. feet aDwelling—No. of Bedrooms------- ...............................Expansion Attic ( ) Garbage Grinder (/VD) p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ......................... ---- . W Design Flow.........r.5..........................gallons per person per day. Total daily flow......... ....................gallons. WSeptic Tank 1 Liquid capacity./-Puv-__gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------/----------- Diameter......../.0..... Depth below inlet......_.--------- Total leaching area..o/t..6._..sq. ft. Z Other Distribution box ) Dosing V /Percolation Test Results Performed by...___ � /est "` r - Date � .Ye �._....__. aTest Pit No. I,Z_�.minutes per inch Depth of Pit.................... Depth to ground water......................... (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 �•�-•g--------------------- -- --- - - ._. -----•-•• -----/--� _ O Description of So 1-------- f�-- 2---- ........'.- ` (, G'-. x W ---- G' -...-• -----•----------. -•-'--•---'- -- -- ---------- ------------ :. UNature o epairs or Alterations—Answer when appli e ••------------------------•-._...............-----•-----------•---------------------•---•..........•---•---•-•-------------------------•---•------•---••----------•-'-••----•-•--•------•----........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T;?..^ y g g p y of the State Sanitary Code— The undersigned further agrees not to place the system in operation until-a Certificate of Compliance has bee issu by the b and of health. oZS Sigd -•-------------------------------- -•----•--------------- ........ Date Application Approved By........ -•---- ----.... �� D to Application Disapproved for the following reasons--------------------------- -----------------------------------------------------------------------------------» -•------•-•----------------------------------------------------------------------•----------------........---------------------------...--------------------------------------------------------....--•-- Date PermitNo......................................................... Issued...................................................... Date N �....... , ............................. o.-.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD . OF• HEALTH ..--_..... -?.t ?.....oF :............... � ----• .................................. Appliration for Mivoii al Vorkti Towitrnrtion pamit Application is hereby made for a Permit.to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .'Grnpr a f rd....te`-'•`�1n. �Gv :.l ..... 'A7r�.... � Location Add e s or Lot No wrier Address a r o h s r e "T�v r�. S.-•... ------------ -- ----------------------------------------------- ------------------------------------ .............•- Installer Address d Tv pe of Building Size Lot...;L1__31b r.Sq. feet U Dwelling—No. of Bedrooms........ _Expansion Attic ( ) Garbage Grinder (JV0 Other—T e of Building ................ No. of persons____________________________ Showers — Cafeteria Other fixtures ;..-:•----=---•-•-•--•••----•--- 0 W Design Flow........... _____________________gallons per person per day. Total daily flow____._.__.�_1.0...:.................gallons. WSeptic Tank-1 Liquid capacity-JIZW.gallons Length................ Width................ Diameter................ Depth................ r x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. f tii Seepage Pit No..........I. -------- Diameter......... :Q.... Depth below inlet..._.._......... Total leaching area_.'7 _:�____sq. ft. z Other Distribution box ( :) Dosing tan '-' Percolation Test Results Performed by __.• -� 1:- �'-'.___ Date.......� y �_f........ aTest Pit No. 1_. '"' _'__minutes per inch Depth of est Pit____________________ Depth to ground water____:____._____________. r34 Test Pit No. 2----------------minutes per inch Depth of Test Pit..................... Depth to ground water______________________-. r , O Description of Soil--------- .- �"`• -----C -;74 -- ___ x I -------•-•----- ---------- ----•---•------•-----•--------:---------------•_...: ----------- ---------- --------________----------------------------------------------------------•••-_--------- r 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 TT T L� p 5 of the State Sanitary Code— The undersigned further agrees not to place-the system in operation until a Certificate of Compliance has bee issu by the b and of health. Sigd. ............................................... ith .....S_. � Date Application Approved BY--•---= •--••- -- -- --�� :._..---••-------- --- 2 5 ---�1 V D e - Application Disapproved for the following reasons-----------------------------------------------------------------------------•--•-------•----------•--...-•------ --•......_..-•----•------•...--------••--•-••--•-------•----------•-••-•---•••-•-••--•----------•--•---••-----------•--•------------•------------------------------------------------------------------ "*r' Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS J_ BOARD F" HEALTH f .......... ....0... ../....OF........ C ..x................................................... Trrtifirate of TompliFana THI S TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) ot-,Repaired (, ) b ......... = ------ --------- Insttaller has been installed in acc dance with the provisions of T 5 of The State Sanitary Code as des ribed in the application.:for Disposal Works Construction Permit No. ... _ ______________ d- ---• �?_. :: _�_________._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE`THAT:THE SYSTEM WILL FUNCTION SATISFACTORY. ' S, DATE......_� `'_ .2. __ ;1.......... Inspector.... {'^l - THE COMMONWEALTH OF MASSACHUSETTS ;; BOARD O HEALT t' . �. ....-....... '" -.....OF..------- ....... .......t......._.... .......,. No.............. -- •-•-•-•---- FEE.. Disposal rkii Cnnnitrnr�ion amit u y Permission is ereby granted ------- !!�'+ .--`--------------------•-------------------.._._.._._._......._.. ::...... "+ to Cons tic ( ) e a><r/(• n ndivldual Sev�tage "s sal Sy at No. `� � � 6 I� Street as shown on the application for Disposal Works Construction r Pe No.. -Dated___ -- _--- g ...� .___._.... o.. -•• -••----------- --- --•. =----------------------- Board Health DATE................................................................................ *. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS PC�hsh M COPY i AW, vk. n 4 S `� 4IN 4' Qf5T. BpK i e no fcF`r. DAM, ooC� o as Go�ic. cacN�u� •P,r c /1 AG4A - JP LS,,+,' T4K << i 45.. 0 4a4 d ' 4A 0 �4 1 �a+Mm�leq s- s Bor• Prr E I44v E5ICAN DA-T-A �vB50�L Z i �C2 Cnt r.t . .�►'TI o Ra-r 2/Ll//j� ,ic LJ D2o 3[�EVR�am�S K Ito GPD - ?3o C PD LEA -crNC-, ,�;64x M�o1U � o C-�Ar-�EVA c4 F DisPo�A� SE � 000 ��i�t� 5fi(c . � SAND CP.F'AGlTy F�GT~r�N1 �5' x /, 0. �B ,SC� Pa .��o 471- D Ac '_c�RD�.NCe -w i T� FZC vrs't.ofy o T! T c o �x-t'E NJ s�4S Est r�01JME TAl- Pv 44 �� LOT leC)0Ij <,J�TaP, a)CO0/.;T} ��� T u /C�-ry 1�CC�vt r THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M A�C(, I DATA _76- D L'c'-r 9 52y G U r vP1 T 471 • 4 � q9x � V - —i-cam'., .r r���i �:'� .�`'.I-�.i' • , _.-. -�.,�-_ T `._ ;f'LO CAT ION SEWAG.E PERMIT NO. VILLAGE IN.S�TA LLER'Sl NAME: & &DDRESS R , OR` WNER DA,T' E PERMIT ISSUED DkT' E COMPLIANCE ISSUED � N v 1 r �l� V,; .� ft