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HomeMy WebLinkAbout0177 LITTLE RIVER ROAD - Health 177 LITTLE RIVER , COTUIT now 0 Commonwealth of Massachusetts , r 51 -- :_: Title 5' fficialInspe'c i®n ®�r Subsu•rface,Sewage Disposal System Form - Not for Voluntary Assessments .��• 177 Little River rd - ------------------------------------------------------ — Property Address Grant and'Susah'Judd Owner _ ----- --- --- --------- - -- �` Owner's Na - - •- •a information is 1� COtult Q77 required for every —_—_ _—_-- M2 026±35 9/9/15` __ ,._, City/Town -- page. 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. Genera�l'l.nforrnation filling out forms on the computer, ``1J use Only the tab key to move your I. inSpeCtOr: cursor-do not Michael DiBuono , use the return, - --- — -- __ . - - ---- ---- --t -- ..Name of Inspecor-_ ____.._.. ._ =. _...._ _ __...__ key. - DiBuono Sewer and Drain ,an Company Name -- ---------- --------.-.---- ---------- 8'Johns path — _- Company Address e,a S Yarmouth ---- -- _ MA 02664 _ City/Town ----- — State -- ---. -Zip Code -------- 508-364-9587 S113522 - - Telephone Number License Number w B. Certification- I 'certify that I have`persona lly inspected the sewage•disoosal system at this address and that the information reported below is true;,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5,(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/10/15 ----------- - Ins ctor's Signature Bate 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal stem• a9 e 1 of 17 i t Commonwealth of Massachusetts _ - `title 5 OfficialInspection Form 1= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a /P. 177 Little River rd Property Address Grant and Susan Judd Owner Owner's Name — information is required for every Cotuit _—__— Ma 02635 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 Pas -y 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 contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ms•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of W I Commonwealth of Massachusetts u _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 177 Little River rd Property Address Grant and Susan Judd Owner - Owner's Name information is required for every Cotuit _ Ka' 02635 9/9/15 page. City/Town State Zip Code Date of Inspection _ B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if .pumps/alarms are repaired. B) System Conditionally Passes (coat.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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: i ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Titleficial Inspeci® Form1� — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /`. 177 Little River rd Property Address Grant and Susan Judd Owner Owner's Name -- -— ---- — information is required for every Cotuit --- ------------- — — Nfr� 02635" y/9715 page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) 2. System will fail unless the Board of Health (and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption, system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This 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. 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 .: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 . Commonwealth of Massachusetts �� -- Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments aP 177 Little River rd _ Property Address --- Grant and Susan Judd Owner — --- ——- --- —- --- -- — Owner's Name information is required for every Cotuit" _ _ I'V19"' 0263_5 9%9%15 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 P p y c well. P ❑ ® 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. ❑ ® 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. I 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection For —� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /p. 177 Li ttle River r d Property Address Grant and Susan Judd Owner -- ----- -- ----------- ...------- ---- Owner's Name -- information is l tut required for every CO _ 1a" 02635 9%971-5- page. Cityllown 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 ❑ Z 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 theywere 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)1, 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 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 177 Little River rd Property Address -------- ----- — -- — — -- _Grant and Susan Judd Owner Owner's Name information is required for every Cotuit Iv?a 02635 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1500 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time ofinspection levels appeared to never have been at abnormal levels. Number of current residents: 2 _ Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d 67 GPD__ 9 ( Y 9 (gP ))� Detail. Sump pump? ❑ Yes ® No Last date of occupancy: 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 I Water meter readings, if available: ------ ---------------..------- 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title ' ffocll Inspection Form - 8 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A 177 Little River rd Property Address Grant and Susan Judd Owner - --- -------------------- -_... -----....-..------ Owner's Name — information is required for every .COtUIt-- --- — --— —' --—.------ Md 026'35 9"/y71'S page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: date — Other (describe below)::. General Information Pumping Records: Source of information: 5/26/2010 —_--- _--_ — 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form —W Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e �,•` 177 Little River rd Property Address --- Grant and Susan Judd Owner Owner's Name information is required for every Cotuit _--_ — Ma_ 02"635 "9/9715- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 years -- Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer (locate on site plan): Depth below grade: 18 -- — 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.): System-is vented throught the roof__- Septic Tank (locate on site plan): Depth below grade: 1 ft _— feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) 1500 gallon - -- ---- — --- --- ---- If tank is metal, Fist age: -------- _—__ years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Gallon Dimensions: 1500 Ga Sludge depth: 3 — -- 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts -s Title 5 OfficialInspection ®r Im' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 177 Little River rd _— Property Address Grant and Susan Judd Owner Owner's Name -- information is Cotuit IVIa 02635 " 919/15' required for every --------------- ----------_-- ---- ------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge-to bottom of outlet tee or baffle 3" Scum thickness --- --- -- - Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structurai'integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: NAfeet 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 t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of (Massachusetts _ W Title 5 Official In ect6®n Form Sub surface Sewag e Disposal S stem.Form - N f y ot.or Voluntary Assessments 177 Little River rd Property Address — - - ------------------ Grant and Susan Judd Owner ----------- ----- ..--- -- - .-.-.._..------- - -- Owner's Name ------_ information is . requ Cotuit Ma 02635 "" ired for every _ 9'19l1"5 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.): Tees are in place and levels are normal 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 El other(explain): Dimensions: Capacity: — -- ---- g a Ilon s ---_------- Design Flow: _-- gallons per day Alarm present: ❑ Yes ❑ No Alarm level: ---------- ------ Alarm in working order: ❑ Yes ❑ No I 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 I 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 177 Little River rd Property Address Grant and Susan Judd Owner Owner's Name information is required for every Cotuit = Ma _ 02635' 9/9/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above 3utlet invert At normal level _ — 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.): Distribution Box is level and at normal level with no signs of carry over or decay__ 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 O Commonwealth of Massachusetts y Title 5 Official Inspection Or Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 177 Little River rd Property Address -- - - - ----- --- Grant and Susan Judd Owner Owner's Name' ---------- ------ ------ - - -- --- -- information is required for every Cotuit _ — _--_ Ma 02635 y/91'1'5 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching.pits, number: --- - — ❑ leaching chambers number: — ---- ® leaching galleries number: 4 Infultrators ❑ 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.): No signs of carry over and no signs of hydraulic failure. 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts �1 _ _ Title 5 Official Inspection Fora — Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments z 177 Little River rd Property Address -- Grant and Susan Judd _ Owner Owner's Name information is required for every Cotuit Ma 02635 9Y9/15 _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of�.onding or hydraulic failure. Privy (locate on site plan).- Materials of construction: — - — — Dimensions — ---. Depth of solids - — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts itlE01 5 Official Inspection Foy �I Subsurface c Sewage Disposal System Form Not for Voluntary Assessments e 177 Little River rd Property Address Grant and Susan Judd Owner Owner's Name information is required for every Cotuit _ _ _ Ma _ 02635_ 9/9/1!5 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 15 of 17 i }} l r ;o: li TOWN OF BAI:.NSTABLE LOCATION /_/ % •i IHe JC/:Lc /" },,0,. Jo � SEWAGE # VILLAGE ��1` l/%_�_ ASSESSOR'S MAP & LOT lf�>5 INSTALLER'S NAME&P.:C..•c SEPTIC TANK CAPACITY v. LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDA'IE: `��� "�`J COMPLIANCE DATE:-_ � Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of•Leaciiing 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(I.f any wetlands exist. (, within 300 feet of leachin fep�lity) Feet Furnished Commonwealth of Massachusetts l V:: `title 5 Official- Inspection Form — ^ Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 177 Little River rd Property Address Grant and Susan Judd Owner Owner's Name information is it _Ma 02635 Cotu 9/y/1`5 required for 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: 14 + ft 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: 9/14/95 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan dated 9/14/95 Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 177 Little River rd Property Address ----- ------------------------ - --- -- Grant and Susan Judd Owner --------- -.._- ------------- —-..._..-..--__..-- -- Owner's Name ---_ " information is required for every COtuit _ _Ma 026 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Ins.p.ectiar,Summaary.D.(.System Failure Criteria�Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I I l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCA'--'ION l7 J !i/ "Jt° �/Bf' /"Of SEWAGE # $�'�7Z 7 VILLAGE Co fz,(l ASSESSOR'S MAP&LOT, INSTALLER'S NAME&PHONE NO. ��r�®��T.��0�7e'J� 771 J I'VIly' SEPTIC TANK CAPACITY � Od LEACHING FACILITY: (type) ����`<��� � (size) ll NO.OF BEDROOMS ff _ BUILDER OR OWNER PERMITDATE: / ' �'" �� COMPLIANCE DATE: l :3 — Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 BA c� h 3 No. Fee t Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppricatiou for Migogai *pztem Conotruction Permit Application is hereby made for a Permit to Construct( )or Repair(.wQjan On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel No. pA Insta egAx, C,%..Address, d Tel.�lo. J� � Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 17 Garbage Grinder jam} If Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow _ 3-30— gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) A l9b m �S qnC..7ih 14_ r Ad i Ont- Date last inspected: Agreement: The undersigned agrees to ensure the construction of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Co e and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi oard f ealt Signed Date 9 /Y e. Application Approved by Application Disapproved for the following reasons Permit No. / ' Date Issued i ——————————————————————————————————————— r . tor# ®Q� `No. '" Fee THE COMMONWEALTH OF MASSACHUSETTS j - r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for Miopozal *potem Cow5truction 30ermtt Application is hereby made for a Permit to Construct( )or Repair(t>/,)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel No. 1-7-7 L r�rl sty,ve/L "Ab Lit+ `— �'00,8 Gov T dVK G�.� /L.k vr`- 2D � ' tM�Ot Installer's Name,Address,and Tel.. 0. Designer's Name,Address and Tel.No. -7 66- �M , ✓VI I��s v 44- Gd tp`l t' E Type of Building: ` y Dwelling No.of Bedrooms 3 Garbage Grinder,(.-) r If Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) I h.)J_,_AA:A 09b tt !j�4 Sf 1<- 7�1�- ` Date last inspected: 1 Agreement: i The undersigned agrees to ensure the construction anaknm of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Co e and not to place the system in operation untiPa Certifi- cate of Compliance has been'issued by th' oar of ealt . Signed Date y/ Application Approved by Application Disapproved for the following reasons Permit No �' Date Issued l THE COMMONWEALTH OF MASSACHUSETTS � PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced.K on by `1�G(Lt ut y i t CV 0 S-_W u C-77 VAJ for .J-U D D q /"7-7 L_ a t 2t J tA- A C-V_rtj%T" has been constructed in accordance with the provisions of Title 5 and the for Disposal System'Construction Permit No. dated � Use of this system is conditioned on compliance with the provisions set forth below: f No. Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwigpool *p5tem Cougtruction Permit Permission is hereby granted to 'r7�U/L'�TUW-57 C--G t1 4-17U Cr7(,^J to construct( fair an On-site Sewage System located at /7"7 G./ TTL /'C.t%JflL, C 0 7- ) i I and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: g"�7 `�� Approved by f i - ° ate.' t�.. _ ,.�.�`"� 0. �� r t,� ' o��we "�� �. 'a �{�3-�'�Y y"'t`' �'- -�.. .. •2.: igs ! tii+x '";� B 1 'j`'J`..5.' > ' ;«.�,`;q'" ♦ ram ' y -az §� a : � RTIFI O `bF. KETCH AND APPLICATION FOR A DISPOSAL y t fy '�pxj _- ��>,°'' O �'C�OSTR���1�1 PERMIT(WITHOUT DESIGNED PLANS) �� . s hereby certify that: he app�tcation for disposal works { 77.77 x s,# cotru ion pernut s end b me dated F t i Bn Y /Yl con g P529 �' cernin the propeity Ioc`ated at /? LiL -t�ir/Z. 0 meets all of the following cntena. v There are no wetlands within 300 feet of the proposed septic system There are no rivate wells within P th n 150 feet of the,proposed septic system observed groundwater table b e is 14 feet or greater below the bottom of the leaching facility ere is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED - DATE: l �/ LICENSED SEPTIC Sys.. INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be'submittedl. ,aar z. 1 Pie- �Af1`9 LN nlp�St� D t �06L lid #/ 77 Ctrry 7"