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HomeMy WebLinkAbout0075 FURLONG WAY - Health 75 FURLONG WAY COTUIT - -- A= 022-084 - - - -- - r F No. V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYitation for Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(✓r'Upgrade( ) Abandon( ) ❑Complete System [�Individual Components Location Address or Lot No. �}S rru r•1 o r\% VJo y, (,o+%;,}• Owner's Name,Address,and Tel.No. Mi 01"I e, 1Z0;Q Q. Assessor's Map/Parcel 6 49� 45 Furl on VJ0, , CAt u,� 50 fe-'}-4(0 114q Installer's Name,Address,and Tel.No. S jb rCaccowo ion Designer's Name,Address,and Tel.No. " 9No01-q, iso , Sa�ndw��h 508 �I�� oc�S3 1�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) it D-b o,4 n a44 yF 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 of Health. Si ed Date �- Z Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �'}�j� ) Date Issued . . j f p- sf No. Fee 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye O"plication for Disposal 6pstent Construction Permit Application for a Permit to Construct( ) Repair(.-'Upgrade( ) Abandon( ) ❑Complete System ®Individual Components Location Address or Lot No. 17 F"r 1 o n% Wo,,-j , Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Q -9� ;)- --0 S Furl o n W c�,I , Co k U,� so l• Installer's Name,Address,and Tel.No. f�3 6 ccx cavc-Con Designer's Name,Address,and Tel.No. 3�`l p�oo�-e 1�� , Sc�nc�wch So2C1�-F • 0(��3 �� 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 L 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 Certificate of Compliance has been issued by this Board of Health. , Si ed Date Application Approved by Date Application Disapproved by Date for the following reasons t` Permit No. nF�''��)T O Date Issued / - ------------------------------------------------------------------------------------------------------------------------- ' 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 P-) F.4 r nk,014 i:,n 1f)at n!u,i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No1,3 dated Installer (��, ('� �.� ,,e_l� , , li)c . Designer �,�n (l- heJ nr,t #bedrooms Approved de i flow d gpd The issuance of this permit shall n t be co strued as a guarantee that the system will fun io designed. Date � Inspector ---------------------------------------------------------------------------------------------- -------- -= -------------- No. ( --" Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at :11� 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 c•mpleted within three years of the date of this pe it. Date �j�// Approved by rn le Tow o f n Ba stab Ins edional Services - y innRNSrnsLc MASS.9. Public Health Division A 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001' 4988`0725 - April 3; 2020 ROJEE, MICHELLE 75 FURLONG WAY COTUIT, MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 75 Furlong Way, Cotuit,MA was inspected on 03/20/2020 by Daniel Hawkins, certified,Title V Septic Inspector for the State of Massachusetts.. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is rotted. • Must remove garbage grinder. You are ordered to replace the distribution box within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas c ean, R.S., Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\C6nditionally Passes Letters\75 Furlong Way Cotuit.doc Town of Barnstable UAKNnABLE, MASS 63 Inspectional Services Department- ,or Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An 'Y' marked in the.o is the faiiure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound-septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to'-An overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ' ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe;relocation of a driveway due to H-10 components,etc) ❑ Leaching facility with standing liquid`level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc ` oaa' - ogq Commonwealth of Massachusetts Title 5 Official Inspection Form T4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way Property Address <r Michele Rojeery Owner Owner's Name information is Cotuit Ma 02635 3-20-20 *. required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist of the end of the form. Important:When filling out forms A. Inspector Information c51* Nqs—cc- _ , on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector +' cursor-do not B&B Excavation key the return Company Name r y 374 Route 130 t ty Company Address Sandwich Ma .02563 City/Town State Zip Code ama (508)477-0653 S114324 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: j 1. ❑ Passes r ` 2. ❑■ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority - 4. ❑ Fails r Digitally signed by Dan Hawkins Dan Hawkins c Date:2o20.03.2412:1437-04•00' 3-20-2020, Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If-the system 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 conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 - _ r cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form Not for Voluntary ryAssessm As sessments 75 Furlong Way.' Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every 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: 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. *Am I i eta septic tank well 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): D-box is in poor condition and needs replacement. Dwelling also has a garbage grinder and system is not designed for it. Grinder will need to be removed. I t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts , �- Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way i ` v� Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town 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 Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ 1ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): , 0 distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): D-box is in poor condition with heavy deterioration. Tank and SAS are in passing .condition. ,• t `yr ❑ 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): ' r 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)(6)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 c � Commonwealth of Massachusetts Title 5 Official Inspection Form I, - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 75 Furlong Way �u Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 ❑ Q Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc°rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 i Commonwealth of Massachusetts �a Title 5 Official Inspection Form 11 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way V Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) a e� 4) System Failure Criteria Applicable to All Systems: (cont.) ; Yes No El ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Q Liquid depth in cesspool is less than 6,below invert or available volume is less than '/day flow ❑ O Required pumping more than'4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ E Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a.public water supply well. x ❑ E Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence ' of ammonia nitrogen and nitrate nitrogen is 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.] ❑ E : The system is a cesspool serving a facility with a design flow of 2000 gpd= 10,000 gpd.. ❑ e Q 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 ❑ ❑ 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c � Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way V� Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every 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 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? 0 ❑ 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? X Were as built plans of the system obtained and examined?(If they were not ❑ ❑ available note as N/A ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 11 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? ❑ El 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ Q 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 .. . ,•e � , , it c Commonwealth of Massachusetts �m Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way V Property Address Michele Rojee . Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information. 1. Residential Flow Conditions: r 3 �._ 3 Number of bedrooms(design): Number of bedrooms(actual):. 330/GPD DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: + " 2 - Number of current residents: Does residence have a garbage grinder? H Yes ❑ No t 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 0 No information in this report.) Laundry system inspected? ❑ Yes No ,^ r Seasonal use? 4❑ Yes .[g No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2018- 67,000gallons 2019- 71,000gallons _ Sump pump? ' . -❑ Yes ❑■ No current Last date of occupancy: s Vt Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c� Commonwealth of Massachusetts �n ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way ` Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day d P Y(gP ) Basis of design flow(seats/persons/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 occupancy/use: Date Other(describe below): 3. Pumping Records: Owner- last pumped 2 years ago Source of information: Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 J. Commonwealth of Massachusetts y . Title 5 Official -Inspection ,Form r 2I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 75 Furlong Way Property Address g 4 Michele Rojee Owner Owner's Name •" .. information is Cotuit Ma 02635 3-20-20 required for every page. City/Town ,. _ 1 State Zip Code Date of Inspection D. System Information (cont.) , } 4. Type of System: L 0. Septic tank, distribution box,-soil absorption system' ' ❑ Single cesspool ,: ib d ❑ Overflow,cesspool r a T • • Privy ­4, k r ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)` ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy,of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP,approval. , R: ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 3. Newest pit added to existing tank and pit in 1994.. - Were sewage odors detected when arriving at the site? ❑ Yes ❑® No 5. Building Sewer(locate on site,plan): k 2r61' Depth below grade C feet A 0' , Material of construction: � ' •` ❑ cast iron. ❑■ 40�PVC , '❑other(explain) # ' " r "Town water Distance from private water supply well or suction line:_. feet - Comments (on condition of joints, venting,evidence•of leakage etc,) " it t5insp.doc-rev.7/26/2018 + Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 18 e Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 75 Furlong Way; V� Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11611 Depth below grade: feet Material of construction: 0 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 1 Dimensions: 000gallons 4�" Sludge depth: 3211 Distance from top of sludge to bottom of outlet tee or baffle 311 Scum thickness G 1I1 Distance from top of scum to top of outlet tee or baffle V 13" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 nf Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 75 Furlong Way v Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State Zip Code Date of Inspection - D. System Information (cont.) 7. Grease Trap(locate on site plan): . NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: - Date Comments(on pumping recommendatioris, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _r 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction.- El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons - Design Flow: gallons per day l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every 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): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in poor condition at the time of inspection. Sides of d-box have deteriorated. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form , - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way ^ . v� Property Address Michele Rojee . Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State . Zip Code Date of Inspection D. System Information (cont.) - 10. Pump Chamber(locate on site plan): r . Pumps in working order: ❑ Yes ❑ No* } Alarms in working order. ❑ Yes ❑ No* s Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. r 11.'Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: , . , (2) 6'x6' pits El '' leaching pits number ❑ leaching chambers number: ' ❑ leaching galleries number: ❑ leaching trenches number, length.: ❑: leaching fields number, dimensions: ❑ overflow.cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form +' w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way �u Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town 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.): The SAS was in working order at the time of inspection. The first pit was full when viewed and the newer pit was dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cam, Commonwealth of Massachusetts . r� Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Furlong Way Property Address - Michele Rojee Owner Owner's Name 9 information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' 13. Privy(locate on site plan): NA{ Materials of construction: Dimensions Depth of solids r - Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 15 of 18 cam, Commonwealth of Massachusetts ,jp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Fdrlong Way Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every State page. City/Town St 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 ASSrSSc7WS MAP 6i LOT,, : t�to 1NST'AL%:iiR'S NAME& PHONE SETIC TANK CAPACITY LEACt-1tNG S1AeC`,.1I-TTyAtVP 140, OF BEDR(>0U.S �.' PIUV'ATE 'W LI O PUSLIC'W. T11M E;IZ11 L]lER pR.C24 NETt ". W. ._ D'A,T>E GK�biFLSA•tV+�:E C55I7EL3.� �, _.:_ ..$✓1� - �_... V,r1RIANCE c;x.Ar4T 1)Z Yes l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 c Commonwealth of Massachusetts - �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments eh � 75 Furlong Way u� Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: + X Check Slope ; ❑■ Surface water ■❑ Check cellar 0 Shallow wells No GW 3' below SAS Estimated depth to high ground water: • feet Please indicate all methods used to determine the high ground water elevation:, h, ❑ Obtained from system design plans on record r . If checked;date of design plan reviewed: Date _ E 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: Bottom elevation of SAS was determined and transfered to a nearby low, dry area. SAS is above high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page.. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �� Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 752Furlong Way . Property Address Michele Rojee Owner Owner's Name information is Cotuit Ma 02635 3-20-20 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0 A. Inspector Information: Complete all fields in this section. 0■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATION 715 F-tjr)otla LJcLSA SEWAGE# ZOZo- l38 VILLAGE Co-4y►i ASSESSOR'S MAP&PARCEL d ®� 7 INSTALLER'S NAME&PHONE NO. EXGayo-A.o y,\ y`lf)- OLS3 SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size)NO.OF BEDROOMS 3 OWNER c PERMIT DATE: T-//- 2 Q 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 Al- G 0, AV ZZ A3• Gy., '' EAR A4. 31 R _ O Z 348 65.9 967 ' Receipt for Certified Mail o No Insurance Coverage Provided =osrMS Do not use for International Mail �ws (See Reverse) Sent to t Str aid No. S � P S _7�IP de O 00 o age M E Certified Fee 8 LL Special Delivery Fee C IL f_es[rect 7.ivery f,etu4n _eceipt- owmg i .to Whos,.m&Date Delivered Return Receipt Showing to Whom, Date,and Addressee's Address TOTAL Postage &Fees Postmark or Date STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). m 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached and present the article at a post office service window or hand it to j your rural carrier(no extra chargel. 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return m address of the article,date,detach and retain the receipt,and mail the article. .c 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. C 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, M endorse RESTRICTED DELIVERY on the front of the article. `o 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If LL return receipt is requested,check the applicable blocks in item 1 of Form 3811. W a 6. Save this receipt and present it if you make inquiry. 10560343.8.0218 Ux Town of Barns a b'le Board of Health 1639. .� 367 Main Street, Hyannis MA 02601 rEp NIR�a Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A Murphy,M.D. Brian R.Grady,R.S. July 22, 1997 David H. Fuller, Trustee 75 Furlong Way Cotuit, MA 02635 It has come to our attention that you own an underground fuel storage tank at 75 Furlong Way, Cotuit. The Town of Barnstable Board of Health Fuel Tank Regulation requires all fuel and chemical storage tank owners to register their tanks with the Board of Health. Please complete the attached registration form and return it to: Public Health Division P.O. Box 534 Hyannis, MA 02601 This registration form must be completed and returned within seven (7) days. PER ORDER OF THE BOARD OF HEALTH r Thomas A. McKean Director of Public Health • PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 022 084- - Account No: 11043 Parent : Location: 0075 FURLONG WAY COTUIT Neighborhood: 08CC Fire Dist : CT Devel Lot : 24 Lot Size : .46 Acres Current Own: FULLER, DAVID H, TRUSTEE State Class : 101 EEJOR FAMILY TRUST No. Bldgs : 1 Area: 1480 75 FURLONG WAY Year Added: COTUIT MA 2635 Deed Date : 050192 Reference : 8030/354 January 1st : FULLER, DAVID H, TRUSTEE Deed MMDD: 0592 Deed Ref : 8030/354 Comments : Values : Land: 21800 Buildings : 75500 Extra Features : 500 Road System: 75 Index: 582 (FURLONG WAY ) Frntg: 179 Index: 1739 (TROUT BROOK ROAD ) Frntg: 136 Control Info: Last Auto Upd: 110495 Status : C Last TACS Update : 012593 Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [022] [085] [ ] [ ] [ ] TOWN OF BARNSTABLE LOCATION (J\ W ?A-q9� �r �' ©K3 SEWAGE AGE # I, VILLAGE ® ASSESSOR'S MAP & LOTO,D%k, P oaf INSTALLER'S NAME & PHONE NO.Ur& ayts cVg, 14-17—OS t SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 6 " BUILDER OR OWNER DATE PERMIT ISSUED: ) n DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L- 4 V 3S 4, SENDER: I also wish to receive the 2 ■Complete items 1 and/or 2 for additional services. to ■Complete items 3,4a,and 4b. following services(for-an N ■Print your name and address on the reverse of this form so that we can return this extra fee): dcard to you. eAttach this form to the front of the,mailpiece,or on the back if space does not 1. ❑ Addressee's Address permit. . m ■Write'Retum Receipt Requested'on the mailpiece below.the article number. 2.❑ Restricted Delivery M t ■The Return Receipt will show to whom the article was delivered and the date .• delivered. Consult postmaster for fee. a 3.Article Addressee to: 4a.Article Number p 0 cc C 4b.Service Type f° ❑ Registered Certified c 'j� of to ❑ Express M ' S"id Insured W � G ❑ Return R ipt a dice ❑ COD w a 7.Date of eii*li eryLOU �.., of 5 5.Received By:L tName) 8.Addres Ad t O uf: equested W W A / and fee fr ll�l�l�t 6.Si atu e.(Addressee or Ag nt); ,£ { ;t:; {;; 0, X t iifiiii ( fi ! t t." t li `: HHiilHI i PS Form 3811, December 1994 102595-97-B-0179 Domestic Return Receipt -- 7 Mq i t Class Mail- UNITED STATES POSTAL SEAVI O a w PM ��;' 'uS'�Sg^i3�&F_ees�Paid a o "Pe�rnifNo:-G--U o.Print your`kaVMW ess, and Public Health Division Town of Barnstable P.O. Box 534 Hyannis, Massachusetts 02g®, i �'1*/Ca"s...�«�Q �y.4 Ilia.aaae�aia�iai�itaaaaa���,axiala�aaat�aataa�aafl'�ialla�aa�a�l Imo_ i - FnBE..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE 14 Appiiration for Di-spnstti Works Tons etc Application is hereby made for a Permit to Construct ( ) or Repair (—I an Individual Sewage Disposal System at: ...........-76 t. - .. ......... _ . t..... ........ .....- - -----------------------------I -------- t . Location-Adl3ress or Lot No. Y . . - '�.. -------• •---------- ----------.......f--...Z!.. �. ---•- -------•----................ O e Qddre Installer Address .< Type of Building Size Lot............................Sq. feet �-t Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of persons............................ Showers YP g -------------•-•------------ P ( ) — Cafeteria ( ) P4Other fixtures -------------------------------------------•-------------------------------- wDesign Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity..........--gallons Length---------------- Width................ Diameter................ Depth................ x Disposal 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ M Test Pit No. 1................minutes per inch Depth of Test Pit...--.---........... Depth to ground water........................ fit Test Pit No. 2................minutes per inch Depth of.Test Pit---z................ Depth to ground water........................ O Description of Soil.............. w U Nature of Repairs or Alteratio s -— y when applicable........ .5- -�.\.............. ..C.-�-...._..-_....... . .........................LQ ..!..........L.----- k. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Env' nmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co anc has been is�y the boar of health. q Sign ............................ ...10........... ............... Date Application Approved By ------------- - .-- -- �. .<.e.�....................... CJ ^re Date Application Disapproved for the following reasons- -- -------------------------- ------------------------------------------------------------------ .....(...-------....... �2— G� Date Permit No. ---------/-_ :-.---- ---- -4'-----_------_---- Issued .....l.U..' �. Cl�.,--- - --------------- Date No ...�4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di-opnsal Works Tntt,llrnrftnn erun# Application is hereby made for a Permit to Construct ( ) or Repair k) an Individual Sewage Disposal System at: "''� ............. .......... .4� `.�. 1�a.. '�'� f .. -------- --------------- Location-Aress r Lot No. :�� `•�� - - ..�..�?. ---------- ..-.--•----- -- �-:. 4 a ._�:�.�.��.\..--•---4�1�.._O_...1��_ ....._ ._..-l..b�......��.�. � �ddres f, ��.--� . Installer Address Type of Building Size Lot............................Sq. feet t-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............... No. of persons........_........._.._....._ Showers — Cafeteria dOther fixtures .----------••----- ------••--•-•--•------•----------------------------•--•----•---•------.............----•----_. W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__._____-____- Depth................ x Disposal 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.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --------•--•--•-------- ••...................•-•••-•----------.....--•---------....--•---------•--....•--...•----••••-•----•-----.........--•---•-•-•------., ODescription of Soil t -..-------•-•--•--------------•--------------------------------------------------------------------•---.--•--•------------- V ----•••--•-•••--•-------•••-------•-•--------------•••-•------•--•--•-•-•---................•---------•---•--------------•-------•----•------•--.................................................... W U Nature of Repairs or Alteratio s— t Je when applicable._.._...''�� _�__. .. _1�.............. .................. 0 0 ------------------------ ......t................................................-------••---•--.................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State En i Qnmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Co lhfiance has been issued by the board of health. Signd- .......... � ` ---------------------------- ---- .......�;te.................. . •, Date III -­ A pp PP lication Approved B Y ,� ------------------------------------------------------------ 1 n ^�T Date Application Disapproved for the following reasons- --------------------------- ----- ----------------------------------------_---------------------_-- --------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -----I-- - .......... c, �+ Date PermitNo. ------... ... -.. L/...-.6... '------------------ Issued ...... ..d... ...5.. .1..�........................ - Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certiftrate of Compliance THIS(CS ITO CERTIFY, That the Individual Sew�aage Disposal System constructed ( ) or Repaired�----� by ...................... ..... ..... ........-- d : LW - Q Installer has been installed in accordance with the provisions oY�'TITLE 5 o The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......... -'Z-------�...?r.... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------ .^ - l -------------------------------............................. Inspector .................. ----•---........................-------- ------------ THE COMMONWEALTH OF MASSACHUSETTS 1 O BOARD OF HEALTH Q �� TOWN OF BARNSTABLE No......................... FEE....3©............ Btspns nrkii Tonotr ion -...... .... v`_�C 1�-5 .........••-•......................... to Construct ( ) or R peg air �t n Individual Sewage Disposal System at No................1 r r -•-----�--_..L"...•..... ..:.._ --- -------- Street [/ as shown on the application for Disposal Works Construction Permit No. <_^l _ Dated.....`_�. ..��.2--...... ........._•-••-•--•-----•--........'. - Q �— ( t ) Board of Health DATE..... ( -------------------------••- �.J FORM 36508 HOBBS&WARREN.INC..PUBLISHERS L0CAT ON. '�� SE,WAGE PERMIT NO. vYt6L VILLAGE , To I� I N S T A LLER'S NAME i ADDRESS Ay- Co -)�, 9 �--� BUILDER OR OWNER 6 ��Y\ DATE PERMIT ISSUED ram ' DATE COMPLIANCE ISSUED r G ` � No............ Fr$... `. ..._ THE COMMONWEALTH OF MASSACHUSETTS "'�► BOAR® 9F HEALTH Appliratiou for Di4vn,ial Works Tomitrurtinn Vernfif Application is hereby made for a Permit to Construct ( ) or Repair ( ) 'an Individual Sewage Disposal System a t;avtQj . W { Lo ation-Address r r ofN bwnr Address ...... ! c ...._.... installer Address QType &f Building i Size Lot............................Sq. feet U ..............................Ex Expansion Attic Garbage Grinder Dwelling—No. of Bedrooms___._._... p ( ) g ( ) `4 Other—T e of Building ...____... No. of persons............................ Showers ( ) — Cafeteria ( ) YP g ---------------= --------—----=---•------•------•-----------. ----•---------•------------------------.................._... Other fixtures --------------•----------------------- W Design Flow.......... gallons per person per day. Total daily flow---------- _36......................gallons. WSeptic Tank—Liquid capacity./PPP—.gallons Length. .-:'k..... Width-4'J-l0._.. Diameter................ Depth...!] x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No..... -- Diameter..... ............ Depth below inlet_.. .'.... __ . Total 1 chin area...`�-n .....sq. ft. >� a�� Z Other Distribution box ( Dosing tank ( ) pc ) Percolation Test Results Performed by..13B.9::lt .1:! t.-�y.P.-. .............. .13.1..r ...... Test Pit No. I..__...�N-----minutes per inch Depth of Test Pit..J_'3.......... Depth to ground water.._._.-............... Test Pit No. 2&U,*,r..minutes per inch Depth of ,Test Pit.................... Depth to ground water........................ O Description of Soil.o%�.A2�:f-. -._ 1i.1!'"� -VL.' -� --------- -------- ---------------------- -----.... •-------------------- -..... U ----------------••----------•------------•-----------------------------------••-----------------------------------------------------•----•- :.... W ---•--•------------------•--------•---------•----------•------•---------•-•-------------------------------•--•-•------------•---...---------•--•--------•------------------------------------.....----•- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ i ...----•------------------------------•-----------•-----------------------•--------------.....---------•--....----------------------------------------------------------------•-------------.......---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance\witlh the provisions of iITI:;. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign ----- • .......................................... _.... Date c� Application Approved BY----. -------- - Application Disapproved for the following reasons------------------------------•-------------------------•----------------__...._......_____ Date A,- -•...............•--..........-•--•--••--••-•---......------....--`-•----...-----•----•-•---•---------•--'--•--•----------•---------------•--------•-......---••---....---•--•-------Date-------_----- PermitNo. ......----•--------•-••------•---------------••------• Issued---- 1----��-................. Date s t 1. ._•...........4_.... '. {Y. 1. a � e.i 4. "2�7 9 i. ..1C....'��y .... i THE GOMMONWEAILTH OF MAS<SACHUSETTS W }Yy, BOARD 9F HEALTH ...........O F...... . Appliratiaan for Bi_gposal Works Tpustrurtiaan fautit Application is hereby made`for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Uj ny c a.J rLocation-Address or Lot�jNo. p - - 2��-- .... �.h:t�.._.._ Owner Address y; a ..............................................Ins.t-.ler.........___._..........._............... ......... ----••_-:r7------- --•ddre's --------------........._.._------------... Installer �`'-„ Address d Type of Building Size Lot---_........................Sq. feet U Dwelling No. of Bedrooms..,.­.:..:...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ). — Cafeteria ( ) PL4Other fixtures ...--_--------_------ ---------------------•-•----------- W Design Flow........=...........................gallons per person per day. Total daily flow.... s CA......._.........._._.......gallons. WSeptic Tank—Liquid capacityb!b'.S__gallons Length"1 .... WidthA. 1.�.'_'... Diameter_____________ _ Depth.__`J'.. x Disposal Trench ''.,,No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------I............ Diameter....--------- Depth below inlet__. .._.._.... Total ,1_9a6ing area. ra.J%_....sq. ft. Z Other Distribution box Dosing tank ►-� Percolation Test Results Performed by.......--•••-•-•--•---------------------•--- ...-•-••-•---••......---_. Date....................................... ,'�.1 Test Pit No. i...... ._...minutes per inch :.Depth of Test'Pit.._ Depth to ground water_-_•_."____----__--.-. Test Pit No. 2..S_L-r 'minutes per inch h,,.;Depth of.Test Pit.................... Depth.to ground water........................ Phi ......................... Description of Soil " . 9C' �� �_t.�l._ ...............� ✓'� . V ---••-•--••---------------------------•--•------•---•------•-•-•••-----------------•---------•- -••-•--•••••••--•------•----•--•-----•-•--••••-••-••----•--•-----------•--•---•-----.........------..... .,, UNature of Repairs or Alterations—Answer when applicable.................................................................................. ......................................=..................................................................._............................................................................................. Agreement: The undersigned agrees to install' the aforedescr'bed Individual Sewage Disposal System in accordance with the provisj,®i s of TITLE 5 of the State Sanitary Code—The undersigned.further agrees not to place the system in operation until a Certificate of Compliance has bee-&J,issued by the board of health. r_ Sig • •---------------•-------•---...._....--•......--•-•-....------------------. ................................ �.. Date Application Approved By = r -3V., = A lication Disapproved for the follow g reasons:............ --°: ` Dat PP ' y Date .r- PermitNo__________________......................... ...... �... j Is$ued__. �_.___ _ " _ _ .__ # �' Date ' y THE COMMONWEALTH OF MASSACHUSETTS 2 ,BOARD OF HEALT .............ro..-W..h .....OF......... ....<•................... Tntifiratt of-Taatnap haurar THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (410'lor Repaired ( ) by........ - _} } at - `----------------------•---- has been installed in accorda7e with trovisions of E` 5 of The State Sanitary.Code as described in the application for Disposal Works Construction Permit No f'6�f------------------ dated THE:ISSUANCE,,,OF THIS CERTIFICATE SHALT. NOTBE:CONSTRUED AS A GUARANTEE HAT THE SYSTEM WIL FUNCTION SATISFACTORY. DATE ... ...................... G.... Inspector...:�� _d �% — -•--- rz THE COMMONWEALTH OF MASSACHUSETTS BOARD OX HEALTH T. { 1 r 'too 1, '2.........OF......... . ... ....... .................................. No......................... ' Dig osal Vorkg Taans#r iaan ami Pec issi n is hereby ranted................................. to Con uc or r ) a dlvidual Se a Dlspo yst at No .�t�l..*� e.4; .......Cq== .. .... /' ' r' t eet ' as shown on the application for Disposal Works ConstructiorPit No ,._.__.'_.____ ____Dateda�-.`*„�„�!'rs-.�9;.!_................................. �� 2 Boar of Health L rs DATE........ ............................. FORM 125.5 HOBBS & WARREN. INC, PUBLISHERS �1=�tc TAaJi� = 33oJ ISc % = 495 G.F, _ D•6o< PJr �715 Po�A� PIT - u 56 loco G 4L, (v �C1�.W�LL AV -A = t5o G.P. ISo S� BOT`rom AREA r C::,o ST- T�oTA L -I >ESl6Q = 42r5 G.►�D'. _Q \ 3W 6.W �.11GDt..QTIC?ll C2l�TE � I{, 2k(I 1J� 02 LES � —4 . . a P m � Op }I �r ) --u U- ►r � fZLO Tor F W =I o Lo4rA B R'Y luv, 91,0 I o0o INV. A SJfisplL 4'pvb bKT. IW 6AL. �(p•�6 -� r -Box 1G• SEPTIC I p A' INV. T-A1IK loon S.8 t LEAGN 94 .o PlT a MeD Wlr�t A. WAS►1ED iSToNE, $9,� LOCATIotJ D Q'j'Ir i S C.A L t h.-T C� t 1/J �enPvS�� CMtzT1l=,-4 TWAT T14t= DwaLL.IkVo 5"owQ S At'l 'fZi= E. N%4?i�L�tJ CC�n.tPL�IS W I'VtA TiAG -SIDCr_- L11-IE: AWE 5��1-t��ne►< �'�q�1�eNct:uT� O Tuc L ZJ, -I`o w L.! ot= 13A i ClA T t= �'�� 7 � • RE61STM-1ZSD LA WD 5UOvEYoL-S Tl-A1'S PLAN4 I L. OT Ot--i 4&j OSTEV-VkL- G 1Wryr�:J:✓�E-:h!i �CJ('`r/C��' ;� �('t1i;: C;s�'l�j%::C�i SI•lGt�IL..D 11F71a't_1 !:l�.h--F�T' ►.L;1- ��t:^-lJ�-,G� T"tay i�(;l-E(�i1,'Ii�JL`: -i._D'Y' l_I l•liw°.`� -~ ^ ��� f���l t`�� j