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HomeMy WebLinkAbout0052 LOVELL'S ROAD - Health 52 €�ove`ll's 'Road Cotuit A = 040 070 i d i c Commonwealth of Massachusetts byb- b� M1 ,? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �r 52 Lovells Rd V Property Address Jason Baird Owner Owner's Na e information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection r 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 filling out forms on the computer, use only the tab Brian Travis key to move your Name of Inspector cursor-do not T&T Title 5 Services use the return Company Name key. 50 Bayden Path Company Address Plymouth MA 02360 City/Town State Zip Code 508-844-7910 SI 13733 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 ofbri-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 10/23/2020 I'nspecto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP: The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts 1� p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any.failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank.failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Rd v Property Address Jason Baird Owner . Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary-Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well.water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ❑ 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 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the. questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El Ely 9 the system is located in a nitrogen sensitive area Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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)] t5insp.doc•rev.7/26/2018 Title 5 Official fnspection Form:Subsurface Sewage Disposal System•Page 6 of 18 L Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: Number of current residents: 7 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readin s, if available last 2 ears usage d 072940 9 ( Y 9 (gP ))� Detail: Sump pump? ® Yes ❑ No Last date of occupancy: OccupiedDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 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: Last pumped in August 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Rd v� Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town 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 I/A 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: 15 years old. Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 3'6" Depth below grade: 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.): All components are intact and fully fuctional. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 3' ' 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: 10.5'X5.5' 1,500 gallons Sludge depth: 1" 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 Distance from bottom of scum to bottom of outlet tee or baffle 12" , How were dimensions determined? Field measurement 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 is in good condition, all components are intact and fully functional. Tank has 2 inlet pipes, both are level. Liquid level is below the outlet inverts. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): t5insp.doc•rev.7/26/201 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 7 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I Commonwealth of Massachusetts Title 5 Official-Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is Cotuit MA 02635 10/23/2020 required for every page. City/Town 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Rd Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020. page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >11 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: 1/16/05 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: i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Rd V Property Address Jason Baird Owner Owner's Name information is required for every Cotuit MA 02635 10/23/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8i Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 w:.1........J:J;:i,.,,..y,.5.,w;'�'_k A.1....Y_v.ivu�"" ..ur..�'4u, „...x.c:«:�...M.a....,: ............. ...._.._..., _..__"_ .___ _._ -,. f ..I 1. �= _s Wuxi AssE§ `b TEST NQLE L❑GS NOTES. ,, , 'A .'$pIL EVAI:.UATOR '1 1�' l G7Y ` f - ;t PARCEL+ 10 .:j �, , _,,.,.. FL1ID0':ZIPff, T-.ADR/tIVYi. ::..:. 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I Jun 20 2017 00;55 HP Fax page 35 40j16— VT-1 01 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h 52 Lovells Road Property Address Paula Faye Owner Owner's Names information is required for every COtuit MA 02635 6-12-17 page. Citylrown 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. General Information 3 filling out formsNttpul+lnrigfr�� on the computer, • ` �� �tH OF,H,q �ii�z' use only the tab 1• Inspector `� � a ya key to move your --i cursor.do not useJames D.Sears ? JAMES ,�,I key the return Name of Inspector Ca wide Enterprises Company Name %, ! •' ... �.... 't r` 153 Commercial Street *"•,1-4;,5 I N S4E 0�'a Company Address Mashpee MA 02649 CitylTown state Zip Code 506-477-8877 S1623 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 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 6-14-17 spector'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 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. t5lns.Eoc• ev.oltfi Title 5 Official Inspection Form:Subsu lace Sewage Disposal System-Page 1 of 17 �n �S Jun 20 2017 00:56 HP Fax page 36 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 52 Lovells Road Property Address Paula Fay Owner Owner's Name information is COtult required for every MA 02635 6-12-17 page. Cilyaown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 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 system is a 1500 Gal.Tank D Box and seven chambers. 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): f 16ins.doc-rev.6,116 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys.em•Page 2 of 17 Jun 20 2017 00:56 HP Fax page 37 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fay Owner Owners Name information is required for every Cotuit MA 02635 6-12-17 page. CityfTown State Zip Code Date of Inspection' B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes(cont.): ❑ 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: ❑ 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 15hs.doc-rev.6116 Tide 5 Masi Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Jun 20 2017 00:57 HP Fax page 38 Commonwealth of Massachusetts Title 5 Official Inspection Form woui-W WU Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �4zj 52 Lovells Road Property Address Paula Fay Owner Owners Name information is required for every COtult MA 02635 6-12-17 page. Cityrrown 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 amopod is less than 6" below invert or available volume is less than day flow t5lns.doc•rev.6116 Tills 5 Officlal hspection form;Subsurface Sewage Disposal System-Page 4 of 17 Jun 20 ,2017 00:57 HP Fax page 39 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments lug 52 Lovells Road Properly Address Paula Fay Owner Owners Name information is required for every Cotuit MA 02635 6-12-17 page. CitylTown State Zip Code Date of Inspection B. Certification (cost.) 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 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 H 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- 10,000g pd. Ej ® 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. t5lns.doC•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 5 of 17 Jun 20 2017 00:57 HP Fax page 40 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 52 Lovells Road Property Address Paula Fay Owner Owner's Name information is required for every Cotuk MA 02635 6-12-17 page. Cityrrown 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 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 Mne.doc•rev.6116 Title 5 Official Inspection Form:$ubaurfeos Sewage Disposal system•page 6 of 17 Jun 20 1 2017 00:58 HP Fax page 41 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fa Owner Owner's Name information is required for every Cotuit MA 02635 6-12-17 page. dilyfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal, Tank D Box and seven chambers. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection [I Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2015-51,00013als Detail: 2016-74,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: Present 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/personslsq.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: I5ine.doc-rev.5/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 Of 17 f Jun 20 2017 00:58 HP Fax page 42 NN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 52 Lovells Road Property Address Paula Fa Owner Owner's Name information Is required for every Cotuit MA 02635 6-12-17 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: NA 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.doc-rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Jun 20, 2017 00:59 HP Fax page 43 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fay Owner Owner's Name information is required forevery Cotult MA 02635 6-12-17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ®. No Building Sewer(locate on site plan): Depth below grade: 44"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. Septic Tank(locate on site plan): Depth below grade: 34" 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: 1500 Gal. Precast H-10 Sludge depth: 2" t5ins.cloc-rev.6118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Jun 20, 2017 00:59 HP Fax page 44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fay Owner Owners Name In formation ormati is required for every Cotuit MA 02635 6-12-17 page. cityfrown 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 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 1711 How were dimensions determined? Asbuiit- Plan-Tape 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 34"below grade wlinlet cover at 18". Two inlet tees, outlet tee. No sign in tank of leakage or over loading 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 t5ma,doc•rev.6116, Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 or 17 I Jun 20, 2017 00:59 HP Fax page 45 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 52 Lovells Road Property Address Paula Fay Owner Owner's Name information is required for every Cotuit MA 02635 5-12-17 page. Cityfrown 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and That switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6116 Title 5 Official Inspection Forth:Stoaurlace Sewage Disposal System-Page 11 of 17 Jun 20 1 2017 00:59 HP Fax page 46 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fay Owner owner's Name information is required forevery Cotuit MA 02635 6-12-17 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 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"xIT-34" below grade w/cover at 14". Box is clean and solid w/three lines out No sign of over loading or solid carry over. 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: t5ins.tlac•rev.tif18 Title 5 Official Inspection Form:SubsuAace Sewage Disposal System•Pape 12 of 17 I Jun 20 2017 01:00 HP Fax page 47 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 52 Lovells Road Property Address Paula Fay Owner Owners Name information is required for every Cotuit MA 02635 6-12-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 7 ❑ 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.): Leaching is seven H-20 infiltrators w/4' stone. Ck D Box-Camera out and probe above and beside chamber's clean w/no sign of over loading 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 t5ina.doc- er.6116 Title 5 Official In"don Form:Subsurface Sewage Disposal System Page 13 of 117 Jun 20 2017 01:00 HP Fax page 48 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fay Owner Owner's Name information is required for every Cotuit MA 02635 6-12-17 page. Citylrown 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.): 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.doc-rev.6116 Title 5 Oftial Inspection Form:Subsurface Sewage Disposal System•Pape 14 of 17 Jun 20, 2017 01:00 HP Fax page 49 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fay Owner Owner's Name information is required for every Cotuit MA 02635 6-12-17 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 i PaaL f R EFAR A B t 7, �_ t ZIP ,A- L r7 3 t5irts.doc•rev.0116 Title 5 Official Inspection Form:Subsurface Sews Disposal pe Sewage p System•Page 15 or 17 r Jun 20. 2017 01:00 HP Fax page 50 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fay Owner Owner's Name information is required for every Cotuit MA 02635 6-12-17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth t high ground water: 11'+ 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: 1-14-05 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plan 1-14-0511'+ No G.W.. Bottom of leaching at 5' below grade. Bottom of leaching at 6'+above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151ns.dac-rev.W6 Title 5 Official Inspection Form:Subvifece Sewage Disposal System-Page 15 of 17 Jun 20, 2017 01:01 HP Fax page 51 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 52 Lovells Road Property Address Paula Fay Owner Owner's Name information is required for every Cotuit MA 02635 6-12-17 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked ® Inspection Summary 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 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposai system•Pepe 17 of 17 t, Town of Barn" stable Regulatory Services h Thomas F.Geder,Director i Public HeWth DiVIS1oII Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 t ' Office:.508-862-4644 Fax: 508-7.90-630e Installer&Designer Certification Form Date: L.. 9 ZCOK,5� Designer: �4yiD � y Installer: 142 ely Address: . 6TU44-1-t Ee- T q 114 Address: 130;" On 0�5- 04A4 i4 was issued a permit to install a (dat ) �n(i-Ttnsstallerr)r��,, septic system at � L �'6v�� based on, design drawn by 2 vim, r (ad s) �� � �✓ � !`t �� dated OZI, (designer) 1-certify that the septic system referenced above was installed substautiall�r according to .�: =. .fie design, which may include minor approved changes such as let relocation of the d 'bution box and/or septic tank. I cerW.Ahat the septic system referenced above was inst al.ted with major c hanger gmater flim 10' lateral relocation of the SAS or any vertical relocationn-of any compone�t of the.sp `e;4ystem)but in accordance with State&Local Regulations_ Plan revisicU or certified as but`by designer to follow. _A_ IDAVU OF te B.llr's a {MASON. rn v NO.10'66. y sq�V1T/1Rt�d. - ��. (Designer's Signature} f s Soap=l3ere} PLEASE RETUM TO BARPTSTABLE PUBLIC HEALTH DrMION. CERTIFfCATE OF C0lV1YL A1V.(: vViLL'NOT :BE M BOTH _T�fS FORM AND AS= QUILT CARD ARE RECEIVED. ]BY THE.B. f; TABLE PtJRhJ[C SI4hT TRANK YOU. Q :Health/Se tic/Desi er Certification Fora 4 P . V 1 / s� c r �� Pg� { r � Assess Road N ` Waterb( E]Par /V Pa, } Buil Wa• fl�'�° �Sta- Misc 4- 4F t ,f Ln� 100 ft I Scale is approximate. This map is for planning purposes only. Produced by Town of Barnstable Parcel lines show on this map are for assessing pi at 09:12 on 1217/2004 NOT represent trut T1c dv✓�Q rM�,.y �tu7�� � Icc.,..�r I\ No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Mioozaf *pztem Con5truction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. V Owner's Name,Add ss and Tel.No. Assessof s ly,'13azcfl�� lI ;1�G"Nlvq d--P IW L �A/ 1��c ,e- 1 Installer's Name,Address,and Tel N f Designer's Name,Address and Tel.No. ,3C A Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmen I Code and not to lace the system in operation until a Certifi- cate of Compliance has been iss is B Fd of " Signe Date ld Application Approved by Date f, 4pplication Disapproved for the following ons 4� Permit No. Date Issued ---------------------------------------- y �`',.Y ��., r 'a�;W.`�- ,�.���ryy,s• V Now!/: � --.� i !�ij 'Fee��V TH'E COMMONWEALTH OF MASSACHUSETTS_ aEntered in computer: Yes "- PUBLIC-HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprication for Mi4po.5af 6p.5ten ' Con.5truction Permit 'Application for a Permit to Construct( )Repair( )Upgrade,( )Abandon(, ) O Complete System ❑Individual Components Location Address or Lot No. 6 Owner's dVame,Address and Tel.No. �L pow nut �/ N. �7 Assessor's IVla�azcel '� � � � s �t71j�LGs Installer's Name,Address,and Tel.N / Designer's Name,Address and Tel.No. 7 401* AS 6.- Type+of Building: Dwelling No.of Bedrooms_(qz=!)— Lot Size sq:ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures . - Design Flow gallons per day. Calculated daily flow gallons. , Plan Date Number of sheets Revision Date -"` + Title . Y ,^ Size of Septic Tank Type of S.A.S. Descriptionlof Soil • s - Nature of Repairs or Alterations(Answer when applicable) ) f y Date last inspected: f :Agreement: The undersigned agrees to ensure the construction and malntenance:ofthe afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ'men al Code and"not to place the system in operation until a Certifi- cate of Compliance has been issued'.y,othis Board of Heialf . �,--- Signe - - ''� Date✓G' " Application Approved by Date Application Disapproved for the following/etons ; l/ ` Permit No. Date Issued i 5 THE COMMONWEALTH OF MASSACHUSETTS s BARNSTABLE, MASSACHUSETTS Certificate of Compliance - , THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by at /_ a v 4 / x- /� has been constructed in accordance with the provisions of Titl 5 and the for Disposal System Construction Permit No. at Installer Designer Designer The issuance of this permit shal not.be construed as a guarantee that the s tstem '4 u nction designed. Date �U' t Inspector I . -... No.-----------------------------------.Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi,5pool *p$tem Construction Permit Permission is hereby granted to Construct S )Repair( )Upgrade( )Abandon System located at is U A /� /Zr� r/ ✓7 �t s ti and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the ates e Date:__�� � _ Approve _ 10/20/2020 ShowAsbuilt(1700X2800) I ' / TO�VnN OF BARNSTABLE LOCATION,QZev �� 2U SEWAGE#2eoC-3S3 , 'VILLAGE 1ki,T . ASSESSOR'S r1AI'&PARCEL " INSTALLERS NAME&PHONE NO./A,z,,v SRO Y>'>s i3!a SEPTIC TANK CAPACITY ef'"y� LEACHING FACILITY:(type)2N%[ yv 1�11 }ge J/.7? No.OF mltoog�s^ S OWNER PERMIT DATE: /O�;ZO S- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 206 feet of teaching facility) Feet Edge of Wedand and Leaching-Facility(If any wetlands exist within 300 feet of leaching facility) Fcet FURNISHED BY AA•z�,� B�Fyt=3S, a https://itsqldb.town.bamstable.ma.us:8431/Home/ShowAsbui It?mp=040070&sq=1 1/1 No.... i_ .7.A Fps...... ./........... _. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town. Barnstable ........ . . .....................................•--.....-------------- Alip ira#ion for ElispogFal Worko Towitrurtinn ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: __�S_.Z M U Lot 2 Lov--ells_,Rd...---C otui t....Mass. --•-•-•--.......0.!. .......U..!.0�b..................................-•- ..... • _.. - ' ' Location-Address or Lot No _Cedar Acres Realty.,••.Trust 24 Great Pond.Dr. -S Yarmouth Ma -- --- ------••------•-•--•---- Owner Address W Cedar Acres Realty, Trust 24 Great Pond Dr. , S. Yarmouth, Ma. Installer Address d Type of Building Size Lot...........000................Sq. feet Dwelling—No. of Bedrooms.._......... ...............................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a d Other fixtures ------------------------------------•--..._..---------.-----------------------•-------------•----...._..--•----••---------------..........------------ W Design Flow...........5 5...........................gallons per person per day. Total daily flow.............3 3 0 gallons. WSeptic Tank—Liquid capacity1000 gallons Length................ Width................ Diameter-----------..... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing,tank ( ) '_4 Percolation Test Results Performed by_ 1N.orman Grossman P.E. Date........................................ Wa Test Pit No. I._..2.........minutes per inch Depth of Test Pit..l1 6 Depth to ground water...none i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•--•-------------------------------------------•-----...------------..............•-•-• --- D Description of Soil....0"-15" sandy loam, 15"-30" subsoil, 30"-13 "....sand •--•-----------------•--------------------------...._....-----------....-----------.............------------.--- V W ---------------------------------------------------------------------------------------•------------------------------------------------------------...----------------•----------------................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •---------------------------------------------------------•--_.._..-•--•---•-------•---......---.........•-••----•-------•-----••-----------------•----•••---•-......•-•••----••-------...........•---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.t 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been"�ed by t bo rd of iealt Signed ......... ..................... .........•--••--.............-- --- � _ - — Application Approved BY " ....../�j //• � �'®t' Date Application Disapproved for the following reasons---------------------------------------------------------------•----------------•---------------•-----.........-- ...--•-------------------------------•-----------•---------------•-•••-•-•--•---------......-•--------------•----...._.......-----•--------............................................................ Date PermitNo....................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........Town.................OF............Barnstable ....................... ...................................:..... Trriifiratr of Tomptianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( k�lor Repaired ( ) b ..... j. ft . ......../'---•-•--•----•-----•-•-••--•••••-•••••-••------•-•------••-......•••••---.....•-••••--•-•...........................•----------•--•--------•-•--••••. Installer � at.._.....- --: ........ - -...... :- - ---------------------------------------------------------------•------------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------Z^7/B.................... dated_._._____.______________._.____...._._._.._.... THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WI FU CTION SATISFACTORY. c/ DATE....... ` .-....0..................................................... Inspector_-. ... -...--------..--.----.--------•-------------.----•----•--•----••---..----- r , No.....$ Fim....... 3.0'' .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ---------Town....................OF...........Barns table Appliratiun for Elhipos al Works Toustrur#ion Prrutit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: ..Lot 2 Loyells Rd. Cotuit.�..Mas..... .... __.. .. --•------•-•--•--•..............................•- Loca ion-Address o Lot No _'Cecat Acres Rea ty� Trust 24 Great Pond fir. S. Yarmouth Ma. ._... --•- . .......--•---•.......... ........•-•------------••--••------•--•--- .........-•-------.......................... Owner ddress a Cedar Acres.Realty, _Trust 24 Great Pond 6r. , S. Yarmouth, Ma. PQ ----------------------------------•-••-----.....-----------------------------•- Installer Address Q Type of Building Size Lot....27,000 Sq. feet U. Dwelling—No. of Bedrooms........... ...............................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building ....... No. of Other—Type g --"-----------=------ --•----------Persons----••---------------------Showers ( ) — Cafeteria ( ) d Other fixtures .----•••---•..............•--•-. •••--- Design Flow_........_.5 5................. . .....gallons per person per day. Total daily flow.............. ......................gallons. w W Septic Tank—Liquid capacity...........1000.gallons Length................ Width................ Diameter..------.---_-- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin tank ( ) '-' Percolation Test Result Performed by... ?Ormc..n Gross...I - Date........................................ a 11 6-11 none 0.4 Test Pit No. 1----------------minutes per-inch Depth of Test Pit...........7...... Depth to ground water.........----........... 44 Test Pit No. 2................minutes per"inch Depth of Test Pit.................... Depth to ground water....................--.. 9 0 0"-Y5�'---sandy.166m;-•-I5W-lu"---subsoil.;--30�=13>�TM saricI----------------------- Descriptionof Soil-"--------"-....---•-------------------------•-"....--•--...-------••--"----•----------------"""--"-....-----"---"...--"--"...............- x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... .............................................•••-----••--- ............•--• /........................... .............................................................. ........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ................................ Date Application Approved BY L : �, t,1 a d D e Application Disapproved for the following reasons-------------•----..........--- --•----•...--•.................................•----•••----••---•--••-•----•--•----:........................---............••-••••-•-••--••-••-••--•...--••••••--•••-•••••-----------•--•------....•--•-- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable .........................OF..................................................................................... Turrtifirtt#r of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( `) or Repairedby ( ) .---• ®,V_."b r7...--"-------------..--•--•--........--------"-"-""-"•----"""•-=..--------.....-----------....------"---•-----•---------....--•-••----••------•---.... ,, Installer at...............`.A a......... -�..J...... ..................0'-r' . ------•-"-----------------------............--------------••--"------------ has been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.--,,,Z--...--------------------------- dated_............................................. THE ISSUANCE OF THIS CERTIFICATE SHAL CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F(INCUbN SATIiUCTORY. DATE...... .- ✓ -&,......-•..................................... --•----- Inspector.... ... ....................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ............................OF...................................................................................... ...... FEE.. .f.�'.:.---... Disposal urku Tony in rrutit r Cedar Acres Rea y rus S Permission is hereby granted----•--•----------------------------------------------------------------- -•--........................ to Constd ct (X ) r Re r ( 1an Idj Se a Disposal System ot 2 dove s Rti u. , ; atNo........................•.........•-•-•-•-•---•---•--------•..........•---....--••--•---•------.•••-•••----------•-•-...•••---.........•••---•-•---.........-•---...... .:........ Street as shown on the application for Disposal Works Construction Permit No..................... Dated..............................:.......... Awli' .E.. t... / DATE..................... oard of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS W No.-------------------- Fee--- BOARD OF HEALTH TOWN OF BARNSTABLE App[ication,forVell Con0ructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location - Address Assessors Map and Parcel ` caner Address --c---- h_.___�1cRY ivl op-- ` � ��Q a��ttilb -------Ll2_4_�3-� Instailtr - Driller Address Type of Building Dwelling-----—------ ---------------------------------- Other - Type of Building - No. of Persons------------------------___—_—_______ o� L Type of Well-----`5------v- - -------- Capacity--- - --------------------------------- Purpose of Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certif' a .of om ' nce has been issued by the Board of Health. Signe — —--�'Zdatel e- --- Application Approved By - - . Application Disapproved for the following re ns:------------------------------------- --------_---_--------_—____________________ ----------------------- ------ --- ------------------------------------ --�--I-J--------------------------------------- date i'Permit No. -- - - -- -- — ---------- Issued ---- - —----------- - - -- --------------------------------------------------- ----------------------------------- - -- - BOARD BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) bY-------------------------------------------------------------------- -------------- --------------------------------------------------------------- ----------------------- Installer at---------------- ----—-- ----- --------------------------------------------- ---------------------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health P ' ate Well Protection Regulation as described in the application for Well Construction Permit No.U 710iXed------------------_____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------—- -------------------------- — -- Inspector--- - —---------------------------------------------------------- I No.-------------------- Fee---41A-- ---------- BOARD OF HEALTH TOWN OF BARNSTABLE Appiication1brVell Construction Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel I 1l,, wner -- Address ---------------------- 1qY--->_YL-" M Installer — Driller t Address Type of Building , / ti Dwelling------ -Y ------------------------------------ ,;. Other - Type of Building ------- No. of Persons-----------------------------_________ Type of Well- -4`�- --T V ----- -- - Capacity-------------------- - - -- __ Purpose of Well----�rr_� -�c 4 �------ d 5 jikryr.2 Y .l ✓1. �I Agreement: The undersigriediagrees� to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to .place the well in operation until a Certifi a .of Compliance has been issued by the Board of Health. Signed --- - - - ---- - - -- ----- � j. Application Approved By- _- -� ' - - - -/ / �J -- - - date ! Application Disapproved for the following re ns:---------------------- -- I - -- -------------------------------- -------------------- i date In i - - ------ Issued ---- - - - - - -------------- 1 Permit No. ----- __ j date -------------------------------------------------------------------------------------------------------- i BOARD OF HEALTH 4 TOWN OF BARNSTABLE r certificate Of Compliance i THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by--------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- ' Installer I has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Wft--7-Qted----------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------- - -- Inspector--------------------------------------------------------------------------- e-____a____v�__________m___—___e_mo__°o_a_omea_____________emo___ BOARD OF HEALTH TOWN OF BARNSTABLE ,well Con5truct ion Permit WM2�1 � Fee Permission is hereby granted- to'Constrc't' ), Alter )�, for Rep a" ( �a Individ WeJ T No. - —Va-� £,-ram= - -�-; - � E-,t 4F -------------------------------------------------------------------- ►SFr t as shown on the a plication for a Well Construction Permit No. - � j t Dated - - -` 4!= - ------------------------- ----------- -- - -- -- --------------------_......_--- Boar d�f Health DATE --- — -- } No. -- Fee---- --------------- BOARD OF HEALTH TOWN OF BARNSTABLE ZippYication,forVell Con0ructionPermit Application is hereby made 4for`a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: _~~ Locatibn —^Address — — Assessors Map and Parcel i41 1Pq n&Qom. 'ESi{eg to -- -- -- A-_� l last Owner _ Address In aher — Driller _ Address Type of Building Dwelling ___ ---- - ------ - Other - Type of Building------___ _—_____ No. of Persons-----------------------._-- Type of Well --- Purpose of Well_Mt-c-:LA13 --_—_ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certific a .of Co fiance has been issued by the Board of Health. Signed S41 Application Approved By / ate Application Disapproved for the following reasons: -- -----------.__----------—---------------_-____ date Permit No. W -D 7 0 Issued date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by---- ___ -- ---- --- --------------------- - —-- ------- ------- --- —Installer at-.- —__—_---_-__-- ----------------------------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Bad of Health Ppvate Well Protection Regulation as described in the application for Well Construction Permit N0. 0972%ated---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE — - —- Inspector-- -- --- __— - ----- - _ P a 4: I ✓/ +w No.- ---- - --- Fee-------------------- BOARD OF HEALTH {� TOWN OF BARNSTABLE , ApplicationArVelr Contruct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repa}r ( )an individual Well at: aLJ Location — Address Assessors Map and Parcel is Qe. Fsfcl}� Owner Address Ins alter — Driller { Address Type of Building Dwelling --1-/- - -- - ---- - -Other - Type of Building--=----_—_ _______ ,. -- - No. of Persons---------------------------------•---• Type of Well ----- - —--- Capacity-- - - - --—-- —- ---—- Purpose of Well---ma's Agreement: ` The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Co pliance has been issued by the Board of Health. Signed - ------- - --1 Application Approved By ® ! � ate !--- ---Application Disapproved for the following reasons:— ——---------------- -- -- date Permit No. ``IL� - -- Issued----- ----------------------------------------- i date i -------------------------------------- -------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired Installer ,.I . at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Pravate Well Protection Regulation as described in the application for Well Construction Permit No.Wx*d/'�_ ated-------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE—--- --------- - Inspector sowmwwi�rwr------------------------------------------------.------------------- ------------r--.-.------.------.-.. BOARD OF HEALTH TOWN OF BARNSTABLE Veil Conf;truct ion Permit /- 4 65 No. ------ — � Fee- ---_—__ Permission is hereby granted to Construct ( ); lti er ( or R pa'". ) nViduaL e11 at: No. --___�- -� _ l Street ' as shown�on the applyic�atio/n for a Well Construction Permit D ��1(27 . 1 No.--� ------ . � - ------ Dated--- ------ e N t----- ------------------- - DATE •~ Board of Health y r of / r �:-- -- ----- ,� ' C r- - a F1 FIIFEIILJILIII _ I - ------------- Ll zc' ' - - - - — - - — �-- - - — —I — - -a- R�sR A-9D iZ-i oN - - NFN S4_oND EIwR F-DDiTlonl - '- i--tiO NT CIEyoF11nU - _ NCw SELoND RooR --— ' 1 9 r I �II It 11 ou 4 -'AOLW F-A'j tF—T uw+ovm e�: - wSWB - wrne r^ - cvTu IT, - ` - FRoNT o�M.w.,mom . `.•' _'< ..' F RtaMT ELEVAT:o7y 1 of i \ I r I I — I I I r r I r I I I I � FF�UIT o'H - E>✓iT C rtQhCC - 0.aSc CC\Lin\C LINE-OF �eU\�y I . 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L k 4 .-: . � Ai: "(Ca ; SOIL EVAWATOR= —1 U!�'' .kI..1­Ix, PARCEL= �.w.- I. . .-.; VERTICAL AATU- .. , �.,; FLpOD ZpNC= J_cT x)F' 'LJGN+� . ., / WITNESS= J .� _. . ;.. - .. - 1 , • DATEi ht i 1 MU N IC L R ER NG '-' "'a IPA 1w/ATER 'AVAI fF E .,E , N . . _ SC D BLE �►' P : CO: A7 N ATE ' 2 h,I ` 1 HE ULE ` Q PVC PaPE TA BE .USED T RAUGH OJT SYSTE UNLESS . w' t-: . IO gTHER jSE ,- _ . . I W NTA. -ate ' - L : 1 :AL '+� .:, o, . : F , , `�` 1. l- PREC T ul� TS, :Tp C[]NFA M IAA,' _ • . a. A SHT 3 . a p } TH 2 , ; n, , "�t ,! ; 5; PIT F� .TH-� PI P 1. ,. ., —'; R1p/. D , �_ . E ISO NO2 , , rri, �. . _ T l.! SS T . • : LOCATION MAP� Y Q 0 ) �.. �, 'ALL CONSTRUCTION DETAILS TQ BE IN CQNf OR ANCE WITH MA, ENVIRONMENTAL 1 . v,,-�I.-.-..,...,...I.,. I..�I..�...�I II­.m 1'-_1'LeLL 3&�..�O.' ��v.,,m�.�,..1-..I.—-,_.-.r.&'1 Ii'(�.,w v;1j:,.-\_ as i "'"""' Ia LO � �T�aNS,q C l)F • CTIT�.E V) AN CA `.REGUL ,Q J ` 71 CQNTRACTQR TO'•VERIFY LOCATIONS Q" ALL U I. � J a � ' �c I TILITIES PRIOR TO CONSTRUCTION, `"!I .. i , � , � . _.`�A: all A ��- � -- l • _ .. . . - . i ! _ ,f. - , . 7F ! :.T . , _ :_.:, ' _ �� >?, I!, , - 1 , 1W . . 01 �.�`;".� I1,.,-I-,.:�4 w4.,.-., II k -...-/0 I..:1.. �s f , � ,\ SE TIC S P " nt _ S T M Iai w : X FLOW ESTIMATE . - z. 104.10 F: '� '�, , , . ti , ;.�� .�. . � . . 1 k r . � ,. 5- , .^� Q BEDROOMS AT �/, GALfDAYIBE ROOM S 4. ti i ;;. n f IIII .,: .,�,. - f �' r lr. A1Y SEPT T . . IC ANK GAL/ . . * v i ., : , ... -. , - - }, + '' .. �R 1 E _ . . �\ .: r 3• „Y _ _ t-_ -r _.. a.. x?k- . . s r - .r .-.. „ „Y .. ,. ,. .. ,a... i', A .1 -.f .. / J , .. ,. .. .. .,,1... i ...r. ,, ,. ,, . . G Y' .. D x A '� Y .... .:. .....+ .... .a a. ., r M.4 r 1. 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