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HomeMy WebLinkAbout0094 FURLONG WAY - Health 94 Furlong Way Cotuit P 022 088 �II d �I ;r i� ;l Aug 01 2019 1720 HP Fax page 1 oaa- 06 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94Furlong Way ` F Property Address Michael Gold Owner r e� Owner's N/one information is COtUIt✓ �Y required for every MA 02635 7-30-19 page. Cfty/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 A. Inspector Information n .fillip out forms . 9 '% on the computer, use only the tab James D.Sears _ JAM ES key to move your Name of Inspector a cursor-do not Capewide Enterprises use the return key. Company Name 153 Commercial Street �'��.p s rNspE���o�`� . Company Address Mash pee MA 02649 ' atylT01^r' State Zip Code w 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 - 7-30-19 spectoi'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. 15insp.doc•rev.7/2 612 01 6 Title 5 Otfkial Inspection Form:Subsurface Sewage Disposal System-Page 1 of to r I Aug 01 2019 17:20 HP Fax page 2 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 941Furlong Way Property Address Michael Gold Owner Owner's Name information is COtUit required for everyMA 02635 7-30-19 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 1000 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): tWsp•doc•rev.R2812018 Title 5 08fdel Inspection Form:Subsurface Sewage Oleposd system•Page 2 o118 Aug 01 2019 1720 HP Fax page 3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 94Furlong Way Property Address Michael Gold Owner Owners Name inforrnation is required for every COIUIt MA 02635 7-30-19 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 pumpslalarms are repaired. ❑ Observation ,of sewage backup or break out or hi h static water 1 g to I i e n the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑`Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (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.7/28/2018 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Aug 01 2019 1720 HP Fax page 4 Commonwealth of Massachusetts - : Title 5 Official Inspection Form Subsurface SewageDisposal sal System Form Not for p Y Voluntary Assessments 94Furlong Way Property Address Michael Gold Owner Owner's Name information is COtUIt required for every MA 02635 7-30-19 page. Cltyt7own State Zip Code Date of Inspection C. Inspection Summary (cons.) 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 fall 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. 4 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 overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to,an overloaded or clogged SAS or cesspool t5lnspAm•rev.7126/2018 Title 5 Oftal Inspection Form:Subsurfsoe Sewage Disposal System•Page 4 of 18 f Aug 01 2019 1720 HP Fax page 5 Commonwealth of Massachusetts : o; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4P 0 94Furlong Way Property Address Michael Gold Owner Owner's Name i don is every Gotult required ed for MA 02635 7.30-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cone.) 4) System Failure Criteria Applicable to All Systems: (corn.) , Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in l,is less than 6" below invert or available volume is less than'/a day flow Pl?l ® 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 CM 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 l5insp.doc-rev.7/26/2018 Title 5 OlAcial Inwec ton Form:Subsurface Sewage Disposal System•Page 5 of 18 Aug 01 2019 17:21 HP Fax page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94Furlong Way Property Address Michael Gold Owner Owner's Name information is required for every Cotuit MA 02635 7-30-19 page. CityfTown State —Zip Code Date of Inspectlon 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)] t5insp.doc•rev.7/262018 7I1le 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Aug 01 2019 17:21 HP Fax page 7 Commonwealth of Massachusetts _ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _94IFurlonq Way - Property Address Michael Gold Owner Owner's Name s Information is required for every Cotuit MA 02635 7-30-19 page. Cltyrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: , 1000 Gal.Tank D Box and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No f Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? - ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2017-48,000Gals 2018-64,000Gal's Detail: t Sump pump? ® Yes ❑ No Last date of occupancy: NA Date t5lnsp.doc rev.71262018 Title 5 Official Inspection Forty;Subsurface Sewage Disposal System-Page 7 or 18 Aug 01 2019 1722 HP Fax page 8 Commonwealth of Massachusetts UTitle 5 Official Inspection Form fSubsurface Sewage Disposal System Form -Not for Voluntary Assessments ti,, 94Furlong Way Property Address Michael Gold Owner Owner's Name information is required for every Cotuit MA 02635 7-30-19 page. City/Town State Zip Code Date of Inspecti n D. System Information (cont.) , 2• Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): - Gallons perch y(gpd) 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: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: _ t5lnsp.doc•rev.M512018 Title 5 Offlclal Inspectlon Forth:Subsurfaoa Sewage Disposal system•page 8 of 1s Aug 01 2019 1722 HP Fax page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 94Fudong Way Property Address. Michael Gold Owner Owner's Name information is required ulred for every Cotull MA 02635 7-30-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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/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 UA 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: NA 2019 New D Box Permit#2019-162. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3811 feet • Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"PVC SCH -40. 15in3p.doc-rev.712012018 Title 5 Of1clal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Aug 01 2019 17:22 HP Fax page 10 Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Up�.p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t. 94Furlon Wa g y Property Address Michael Gold Owner Owner's Name information Is required for every Cotuit MA 02635 7-30-19 page. CitylTown State Zip Code Date of Inspection D. System Information (cost.) 6. Septic Tank(locate on site plan): Depth below grade: 28"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene, yl ❑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: 1000 Gal. Precast H-10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 011 Distance from top of scum to top of outlet tee or baffle 811 'Distance from bottom of scum to bottom of outlet tee or baffle 1 B„ How were dimensions determined? Asbuilt-Tank Sludge 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.Tank and outlet cover at 28"below grade wlinlet cover at 10". Inlet Tee w/outlet baffle.No sign of leakage or over loading t5inspdoc•rev.712612018 Title 5 09ciel Inspection Farr;Subsurface Sewage Disposal System•Page 10 of 18 Aug 01 2019 17:23 HP Fax page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94Furlong Way t Property Address „ Michael Gold Owner Owner's Name Information is required for every Cotuit MA 02635 7-30-19 page, Cityrrown 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.): A B. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): � r Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: - Capacity: gallons Design Flow, gallons per day t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page t t of 18 Aug 01 2019 17:23 HP Fax page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form ' ' i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94Furlong Way Property Address Michael Gold Owner Owner's Name - i formation is required for every CotUit MA 02635 7-30-19 page. City/Town State Zip Code Date of inspection D. System Information (cont.) 8. Tight_or Holding Tank(cost.) Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date.of last pumping: Data 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 16"x 16"4'below grade w/one line out Box is New 2019 w/cover at 6" 151nsp.doc•rev.7/252018 Title 5 offidal Inspection Form:Subsurface Sewage 01spoaal system-Page 12 of 18 Aug 01 2019 1723 HP Fax page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 94Furlong Way Property Address Michael Gold Owner Owner's Name information is required for every CotUit MA 02635 7-30-19 per, City/Town State Zip Code Date of Inspection D. System Information (cant.) 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number ❑ Teaching trenches - number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: t5insp.doc•rev.7/2&2015 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 19 of 18 s Aug 01 2019 17:23 HP Fax page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94Furlong Way Property Address Michael Gold Owner Owner's Name information is required for every Cottia MA 02635 7-30-19 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.): Leaching is a 1000 Gal, precast pit. Pit at 3"below grade. Pit is dry w1stain line at 20"off bottom. No sign of over loading or solid carry over. 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 ❑ Ye' ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t6insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18 Aug 01 2019 17:24 HP Fax page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form hSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 94Furlong Way Property Address Michael Gold Owner Owner's Name information is Cotuit AAA 02635 7-30-19 required for every Cit /Town page y 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.): R t5insp.doc•rev.T12612018 Title 5 official Inspection Forth!Subsurface Sewage Disposal System-Page 15 of 16 Aug 01 2019 1724 HP Fax page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 94Furlon Wa .__. g Y Property Address Michael Gold Owner Owner's Name information is required for every Cotuit MA _ 02635 7-30-19 page. City/Town State Zip Code Date of Inspectlon 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 R g L7 o - A-r= 9 Q-+- N� I 14.3 19- ?= 43-' 0-a/- 77, f i;rma,doc•n.rr�enos y r*60AeA1 Nw:w Paan:euowhr•sway,@ Obpow bream"Pq-tea to B6 akd xEJ cH Biel 6loz ro AeW Aug 01 2019- 1724 HP Fax page 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94Furlong Way Property Address Michael Gold Owner Owner's Name information is required for every Cotuit MA 02635 7-30-19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 0 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 14 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: pate ® 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: Auger T.H. 14' no G.W.. Bottom of pit at 9' below grade Bottom of pit at 5'above T H Depth E 1 Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.712612018 Tills 5 Orficlal Inspectlon Form:Subsurface Sewage Uspoael System•Page 17 or 16 t Aug 01 2019 1724 HP Fax page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94Furlong Way Property Address Michael Gold Owner Owners Name Information is Cotuit MA 02635 7-30-19 required for every page, City/Town Siate 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 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 a n , t5insp.doc•rev.7126/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 i 0 rr No. o( Fee 75� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftphtation for Bisposal Opstem Construction Permit Application for a Permit to Construct( ) Repair()� Upgrade( ) Abandon( ) ❑Complete System 1XIndividual Components Location Address or Lot No. C( �(yR W Owner's Name,Address,and Tel.No. Assessor's Map/Parcel FAG. LV d0--rV rT Installer's Name,Address,and Tel.No. 501?-q-11—S 8 77 Designer's Name,Address,and Tel.No. d°10 - 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) 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. Signed Date 5^7 —aO f a Application Approved by ( Date 7 .Application Disapproved by Date for the following reasons .Permit No. ao n Date Issued j-- Lt I Fee No. 2o(� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s 2pplifation for Disposal 6pstrm Construction 3permit Application for a Permit to Construct( j Repair(IV Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.94 FV1�LW6c, wk( Owner's Name,Address,and Tel No. Assessor'sMap/Parcel TUtT lN1tCNAr2k. �o� Installer's Name,Address,and Tel.No. 509-4'1Z—Sg 77 Designer's Name,Address,and Tel.No. i CAPG,,J(UG I PI io 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)C�~ ) �-{ p A _"(3,� ►( t tdJ L—J)+ Tll 1!!'5, A Date last inspected: ~ 4-Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in s' accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of rt4 ` Compliance has been issued by this Board of Health. Signed Date Application Approved by �r Date S Application Disapproved by Dat&. for the following reasons .,Permit No.t` 62 c)ICI^ 6�" Date Issued — -i THE COMMONWEALTH OF MASSACHUSETTS - lJ BARNSTABLE,MASSACHUSETTS Q f`) (fECtifILate of Compliance THIS IS TO CERTIFY,that the On-si a Sewage Disposal system Constructed( ) Repaired(,�O Upgraded( ) Abandoned( )by�:APEW l D , \\ has been constructed in accordance at q 4 Fla-LnA k-- with the provisions of Title 5 and the for Disposal System Construction Permit No. pI —1 6Z-dated Installer (ZACOFLA I IDE 4 Designer #bedrooms Approved desigtr'flw� , gpd The issuance of this ffpehnit shall.not be construed as a guarantee that the system wil function/as design d.(� Date (I L r Inspector ` W t t i --- - -- --------- ---------------------,------------------ --------------------------------------.--------- ------------.-- No. C)61 ( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoSal 6pstem Construction J)Prmtt Permission is hereby granted to Construct( ) Repair(t Upgrade( ) Abandon( ) System located at QCL V�(_ ax ) 1 ' !!_-( 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 7 Approved by c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Furlong Way 14%n) Property Address Mary Crehan l/2 L OU Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name rzb. P.O.Box 763 Company Address Centerville Ma. 02632 eam City/Town State Zip Code . (508)428-4028 S14454 Telephone Number. License.Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the ins'pection.rTbe inspection was performed based on my training and experience in the proper function and maintenance of oirsite sewage disposal systems. I am a DEP approved system inspector pursuant to Sectionr-5.34-of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Faiisi `3 ❑ Needs Further Evaluation by the Local Approving Authority rn 2/15/2008 Insp or'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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cwM 94 Furlong Way -' Property Address Mary Crehan Owner Owner's Name information is Cotuit Ma. 02635 2/15/2008 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes:. ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced h ❑ obstruction is removed 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Furlong Way 4M y00 y`0 . Property Address Mary Crehan Owner Owner's Name information is Cotuit Ma. 02635 2/15/2008 required,for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts` W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) C) Further.Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must,be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each'of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool . ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 El ® than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 94 Furlong way-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I ' Commonwealth of Massachusetts - N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is .Cotuit Ma. 02635 2/15/2008 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. J ❑ ® The system fails. I have determined that one.or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was providedjby 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ' ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 LN Commonwealth of Massachusetts W Title 5. Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 94 Furlong Way. Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? Ell Yes ® No Water meter readings, if available last 2 ears usage d 2007:114,00 • g ( y g (gpd)): 2007:114,000 Sump pump? ❑ Yes ® No Last date of occupancy: 2/15/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑, Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Furlong Way" P rope rty.Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: 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: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared.system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 `Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2, Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years. Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'6"x4'10"x57' 411 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 4" Scum thickness 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 101, How were dimensions determined? Measured 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. City/Town State Zip Code Date of Inspection D: System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet.invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outler tees are.in place.No evidence of Ieakage.Tank appears to be structurally sound. 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.): 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): 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. CitIy/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑-'No 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gallon ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name-of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line is 36" below invert pipe. 1 94 Furlong way•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Privy(locate on site plan): Materials of construction: J Dimensions Depth of solids Comments (note condition of soil; signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ®. Zoom Out I M , In y r K.r K r{- - 'r �a a y. { � V < 46 9 . s z _ W. f - A L• ` y 'J� a II ..♦ OQ Jr E m I r tr a k � } y♦ ..c—�` 1 YJ ;.� cr ` I ♦ `41(� i ♦ r'' PY , 20 Feet , INT Set-Scale 1" = 20 " I Aerial Photos of P--f�hio nnv AJI rhtit. http://www.town.bamstable.ma.,us/arcims/appgeoapp/map.aspx?propertyID=02208 8&map... 2/15/2008 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 94 Furlong Way Property Address Mary Crehan Owner Owner's Name information is required for Cotuit Ma. 02635 2/15/2008 every page. . City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:Gaherty& Miller model.12/16/94 ground water elevations.USED:USGS observation well data.USE D:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 94 Furlong way•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable Op IKE 1p� Regulatory Services ;QsARxsrABM Thomas F. Geiler, Director v 19. . prfp�,�A Public Health _Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is:certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/coP y of this report; this Division does not warra nty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. in addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding.this report, please contact the certified Septic System Inspector who conducted the inspection. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A .. .'�ilk ARM TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: . Owner's Nam / RECEIVED Owner's Addre s: Date of Inspection: i5' OCT 2 6 2004 Name of Inspector• (please print) TOWN OF BARNSTABLE Company Name _ Q HEALTH DEPT. Mailing Address: �-IA Telephone Number: �9 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this'address and that the information reported below is true, accurate.and complete as of the time of the inspection. The inspection was performed based on siy training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP - approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes . Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner:. AW Date of I spection. Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D. A. System Passes: J— I have not found any information which indicates that any of the failure criteria described in 310 CMR 15:303 or in 310 CNIR 15.304 exist.Any.failure criteria not evaluated are indicated below. Comments: & System Conditionally Passes:. One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is.metal and over 20.years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution,box due to broken or obstructed pipes)or due to a broken,settled or uneven distribution box. System will pass inspection if(with.. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system.required pumping more.than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner;- � �VA ' Date of speetion C. Further.Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. . 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system.is functioning in a_manner that protects the public health,safety and environment: _ The system has a septic tank.and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has aseptic tank and SAS and the SAS is less than 100.feet but.50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal'to or less than 5 ppm,provided that no other failure criteria are triggered. A-copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL:INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _ Owner: _ Date of D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N9 ✓ Backup of sewage into facility or system component clue to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface.waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution_box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow 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. _ V Any portion.of a cesspool or privy is within a Zone 1 of a public well.' Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or.privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed.at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates thatthe:well is..free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria. are triggered. A copy of the analysis must be attached.to this form.] NO (Yes/No)The system fails: I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.301,the the system fails. The system owner should contact the Board of Health to determine what will be necessary to correctthe failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to.15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the.system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B , CHECKLIST Property Address: Owner Date of Aispeactio4t &5 Check if the following have been done. You must indicate"yes"or' "'no"as to each of the following: . VYes —o - •. t, _ .�. �. '.� . . . . ,. , 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? _ H s the system received normal flows in the previous two week period ? Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note.as N/A) Was the facility or dwelling inspected for.signs of sewage back up Was the site inspected for signs of breakout? _ Were all system components,excluding the SAS, located on site i_ ere the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition ftl1ebaffl:s 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 P P P maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes o Existing information.For example, a plan.at the Board of Health, _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)) Page 6 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner Date of,n ppe cation / C/ ELOW CONDITIONS RESIDENTIAL Number of bedrooms.(design): .. Number of bedrooms(actual): DESIGN flow based on 310 C ]5.203 (for example: 11.0 gpd x#of bedrooms):—" LJ Number of current residents: Does residence.have a garbage grinder(yes or-no): - u - Is laundry on a separate sewage system (yes or io); if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): O... Water meter readings, if available(last 2 years usage(gpd)): (Z , 0� / (� Sump pump(yes or no):L2V Last date of occupancy: COMMERCIAUINDUSTRIAL ,-V'16� Type of establishment:. Design flow(based on 310 CMR.15.203): gpd Basis of design.flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):-_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the in pection(yes or o): If yes, volume-pumped: gal-lons=-How was quantity pumped deterniin'ed?`= Reason Tor.pumping: 4TYP � OF SYSTEM eptic tank, distribution box,soil absorption system _Sing cesspool Overflow cesspool —_I'rrvy _Shared system.(yes or no)(if yes, attach previous inspection records, if any) _Imnovative/Alternative technology,Attach a copy of the current operation and maintenance contract(to be obtained from system owner). _Tight tank _Attach a copy'. opy of the DEP.approval —Other(describe): roximate age of all compou uts,(late installed (if known)and source of information: Were sewage odors detected when arriving.at the site(yes or no). 6 Page 7 of I I f` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOWM PART C SYSTEM INFORMATION(continued) Property Address: o� Owner: 2PLJ Date of I spection (9� P BUILDING SEWER(locate on site.plan)//W Depth below grade: Materials of construction: cast iron 40 PVC other(explain) ,. Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) P a De th below grade: Material of construction: oncrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:' X(a k S Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: — Distance from top of scum to top of outlet tee or baffle: 2, Distance from bottom of scum to bolt o outlet tee or baffle' How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evide ce of leakage,A c.): ' GREASE TRA:(locate on site plan). /� Depth below grade:_ Material of construction:_concrete - metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness:. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Addressi AA , Owner:, / lo����G►�'� Date of Ins ectio ': a ao TIGHT or HOLDING TANI5 U(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:. T- gallons/day Alarm present(yes or no): Alarm level: I Alarm in working order(yes.or no): Date of last pumpir'g: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:i—e—lof present must be opened)(locate on site plan) Depth of liquid lev'I above outlet invert: �.(,�(1Ly Comments(note if�box is level and distribution to outlet qual,any evidence of solids carryover,any evidence of kage into or out of box, tc i. 4 PUMP CHAMBE (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no).: Comments(note.c ndition of pump chamber,condition of pumps and appurtenances,etc.): i i i i i i I i t 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: .��V,:��,fA .Owner: Date of I pection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type... �eaching pits,number:L ' leaching chambers, number: leaching galleries, number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil;condition of vegetation. c)' CESSPOOLS (cesspool must be pumped as part of inspect ion)(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: Y Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY:(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. Owner:zut , Date.of spectiofr S, > SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the.building. ✓2� 0,/ �q (0) L33 �f 1 3° i �ezbt��c� I�bco ee.l�,� 10 Page 1 l of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propert Address: 5� •off Owner. rA Date of spectio /. SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high.ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) 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: g 11 Permit Number: Date: Completed by: x1 HIGH GROUND-WATER LEVEL COMPUTATION Site Location: /(,� �. ��. Lot No. Owner: Address: Contractor: G9 Address Notes: ��s�/P5 STEP 1 Measure depth to water table to nearest 1/10 ft. .................................`............................................. .Date _. month/day1year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... OB Water-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for,.index well ..............:... month/year 4 STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) 37 determine water-level adjustment .......................................................................................... ° STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site. (STEP 1) ............................................................................................................. Figure 13.--Reproducible computation forma 15 lea /G)ij'C>�l�/ ..........1.] ar . I r TOWN OF BA STABLE LOCATIONS Io SEWAGE # 8C O VILLAGE ASSESSOR'S MAP 6T LOT'f INSTALLER'S NAME 61 PHONE NO.( � SEPTIC TANK CAPACITY ���_ LEACHING FACILITY:(type) (size) �. NO. OF BEDROOMS PRIVATE WELL OR P LIC WATER BUILDER OR OWNER Acim� DATE PERMIT ISSUED: GD o DATE COMPLIANCE ISSUED: -7- -�y - c/ VARIANCE GRANTED: Yes No / �' ( r ;�1 Z THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -U---------------OF:. VZ _1 ........................... Allp ira#ion for Uhipwial Works Tuuitrurtiou Prruat Application is hereby made for a Permit to Construct (i ,) or Repair ( ) an Individual Sewage Disposal System at: ....... . .....&& Locatio -Add or Lot No. Av /_.. �" �Y� _.. ---•--•------- ..........-----------------------•-----•--.....------......----------•---------..._..._...-------- Owner Address W r ,a .r� 'f --------------- -------- ---------------------------- Installer Address Type of Building 15 Size Lot.Z;-40-----Sq. f et Dwelling—No. of Bedrooms............................................Expansion Attic 40 Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) —.Cafeteria ( ) Otherfixtures -----------------------•-------•-----------------------•-•----------------------------.-----------------•-------------------------------------------- W Design Flow........5 57........................gallons per person per day. Total daily flow-------3 ........................gallons. Ix Septic Tank—Liquid capacityNCM.gallons'* Length................ Width................ Diameter---------------- Depth................. Disposal Trench—No. .................--- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit NO------- ------------ ---- ----- Depth below inlet...... .........-Total leaching area__?J.C.0..... ft. Z Other Distribution box Y05 Dosing tank Percolation Test Results Performed by._ -13 2 .. ............................. Date....A. ©_"�`� )._--__. Test Pit No. I...42.......minutes per inch Depth of Test Pit--__14.......... Depth to ground water.�Q� QUA 44 Test Pit No. 2...4,�......minutes per inch Depth of Test Pit___.-�.C>-___-_-- Depth to lzround water--------b--__-___--_- Description of Soil............;. . ... ...1M. _: 2 4 ._v_ n?. �._ �--. .-V ---t - W _ M L.( x ------ - - -------�-� - --1�c .........................`..................................................... U Nature of Repairs or Alterations=Answer when applicable------------------------------------------_............................--------------_.........__ ----------------------------•-------------------•-----------------•--------•-----------..........-------------•-•------------------------------------------- .................................-......... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T t'1..... the provisions of f'1 ILi 5 of the State Sanitar_Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been board of health. Signe . ••------•- ........... .. .......................................... Date Application Approved By--------------- . "'"" ----•-------fr Date Application Disapproved for the following reasons:----•-----------------------•-•------------•---------------••--------------------------------•--......--------- -----------------------------•--------•-----------....------.......-----------------------...-----...................----------------------------•-----------------------...--------------------•-------- Date Permit No....... 4-�-- -�--�-•------------------------ Issued_---=------ - --- s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,f..n...1.............. i OF... �VZ) �....... . . 1 AvOiration for Disposal Works Toustrnrtiun jhrmit Application is hereby made for a Permit to Construct O) or Repair ( ) an Individual Sewage Disposal Systemat: ��^^ .............................................i�..C�o._.��. �� Q '..! -••---------.�t�. ._._........ .....------------ ---••-----------------------------•-----•- . ocatio ddres or Lot No. ZA - ..... ...........................••------.._.._....----•----•-...... ..................................... ........................................................ Owner Address W ...' •-------•----- -------------•--- ---•--------------------•----------------- Installer Address Type of Building Size Lot..ZZl.°I'•••�_0._..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (06 Garbage Grinder Met) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------------------------------------•---------•--------•--------------••••-•--...••••-•--•-•-•------•-••---....._...-•-- W Design Flow......... ._`-�........................gallons per person per day. Total daily flow.:_.... D.................._....gallons. 9 Septic Tank—Liquid capacity.N4 ?gallons Length................ Width................ Diameter---------------- Depth................ 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 Eb Dosing tank (��0) Percolation Test Results Performed by--- +1_ t �=.. _._,* �- :..................... Date.... ���. . ........ a _ ,a Test Pit No. 1... .......minutespermch Depth of Test Pit..... .......... Depth to ground waterl__4_-`- 'JIY?:( .3 G14 Test Pit No. 2--- minutes per inch Depth of Test Pit C7 Depth to ground water ___--_-___. Pd ! 41` �' ` `�t L,-•-•-•S==f i'e i+ `ri.�� , f tr C'1C... Description of Soil----;r �- � ---......._`... �.�+�.t �L� ��t�ZJ � � ���� -------`!�-�•`�--.�71r_�„�__.• _I W .................................................................°C� . t. � ....._...��..� ...SC:..,_ f�......° ------------- ----- -------- -------------------- -----------------------------•--- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------•____________________________-___-----•----_----. --------•---------------------------------------------------------•----------------•--••------•---•----•--....------------. ----------.............-----------------------------------------••------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I'LPIE 5 of the State Sanitar Code—The undersigned further agrees not to place the system in`` operation until a Certificate of Compliance h been tlre;board of health. Signe __. Date Application Approved B "' Date Application Disapproved for the following reasons---------------••--------••--•--•----•-------------------------•-----------------------------------.....----•---- ------•------------•-----•-••---------•-----------------•-•-....-••••--•-....--•---------------...........•••--•••-------------------...----------------•---•......-•-----•----------•.•----••-------•--- Date PermitNo....... _t.. ................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .4 A................O F........ t,-,,+ ......................................... guntgfictttp of Toutpliaanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired2 4 ( ) ...: ......... �f•• --------- In taller at-•-•--------------�n1-------I 6.......F•--• -----------------------------•------------------------ has been installed in accordance with the provi ons of TIT 5 of Th State Sanitary Code as described in the application for Disposal Works Construction Permit No............. ....`.�•,��Z.__. dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT.B.E CONSTRUED AS A GUARANTEE.THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATEDATE... �.. .�= D-- ........................ Inspector...----------- :..1 -•-----•---------------•----------•---------••--•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p ¢r1 ............ ............OF......... cX^ Dispostal prk uan Fermi Permission is hereby granted..............��-___16 ........ � ....... ................................. to Construct ,orr Repair ( an Individual Sewage DisposalAW at No..---•---•••-1~ _s+-•� lr _LA..... �'� ti(,e! ' -.. ------- -------------------•--------•----•-----_----------------- V Street as shown on the application for Disposal Works Construction Permit No. b.. Dated.......................................... �.. Board of Health DATE..............e----..`.)..X- ---•i... •---.....------......-=--- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - j=L.�-h..1 �to�, 1.fi3 i 1��`�J'�?L-.p��..l�,�-\�l.,li4�( a••r, ; 2�A Eb," WA-T-so l d � L�E 5 t If,NA l 'A,TA 5 t kl TAM L'( - �— �� �ftiR'3+°efx� C�ItiaA�i� `C t=�a�c./ � t t a x 3 33a�� 0� :2 ►o � �•o �' ��� S E1�T1G 1 x��C 33a % = g95GP-? ' LA 5� loop C U O► S .-; __----s` - wI'M 1` 00 ' -77 Z. �4 5 rvt`wa��.t_� Auk Ck�AGtT� :tsp SF C 2,5 = 31 S GP' Nj �a.ca. : SaaF T oTq t_ -7>r516c Q Lo 4. 425 C-E FT? `� IIaG of � �t �KGa1.laTlaNT�a�TC IiVZ01� 1i.11 2Mir_1.42L655 + j ) i 1 L?t5ec-7b VC.I TJ4I, `j tZ"oV-V G<<,��.\ LA.lxr Fee- Assm.. Ty-� 5T Hot_ 4o 76 (,moo Acco Trl- e1 t-G� Q Tay aF Fti1t7 ToP`A'L � ���•�� IoaZ? o'A .3 CTtii, S3 5 tt_c. �-� 82.E �Nv �Nv o• ,.� 4To)�U/5H � CAA Q�: s-muE e>�: " . . wit VIP _�. 1E...�. tJ4 ��z ! ` `t_f.j_.l i � D cA,P -72:.7 of 4;41s -- 9i 1 - HTER .o SULLIVANSllLLIV AN cent 5'S 2� trj �_� 7 �10. 29733 oc • .A�' '� ------------- i