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HomeMy WebLinkAbout0465 MAIN STREET (COTUIT) - Health 465 Main Street Cotuit A= 022 — 135 r d I D Commonwealth of Massachusetts RIMTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address GPI L �C Owner Owner's Name information is required for State Zip Code Date of Inspection every page. City/Town P P Inspection results must be submitted ort'this form. Inspection forms may not be altered in any. way. Please see completeness checklist4t the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: onlythe tab key Y to move your cursor-do not use the return Name of Inspector key. i /yl o — T LC, Company Name Company Address i_- aS CIS 6�� City/Town State Zip Code j Od / / 7 Z� Telephone N ber 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, accurateand 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 ra 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 OP Needs Further Evaluation by the.;Local Approving Authority Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of theIDEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. i ****This report only describes conditions;at the time of inspection and under the conditions of use at that time. This inspection does no'Vaddress how the system will perform in the future under the same or different conditions o17 use. II t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System•Page 1 of 17 Commonwealth of Massachusetts? MMF� Title 5 official Inspection Form Subsurface Sewage Disposal System:'Form - Not for Voluntary Assessments Property Address / C, 0 G Owner Owner's Name 1 �� information is / N r / //t �S 3 required for Co Oo16. every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,p or E/always complete all of Section D A) System Passes: I have not found any information,which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 substartiali 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): l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts ID i i ' Title 5 Official Insfipect��on Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address / � G Owner Owner's Name / information is (/ I f 0c)6 3.; 4ef /rcrtrequired for State Zip Code on every page. City/Town B. Certification (cont.) 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 moireithan 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts' Title 5 Official Inspodti-on Form) Subsurface Se/wage Disposal System'For:m -Not for VoluntaryAssessments Property Address vl C, Owner Owner's Name information is CA�w I f o a 6-3s required for — every page. City/Town State Zip Code Date 6f Insp ction 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 icertified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or'cesspool Discharge or ponding of effluent to the surface of the ground or surface waters e ❑ due to an overloaded or clogged SAS or cesspool ❑ Static liquid level inithe distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool!is less than B"below invert or available volume is less than Y2 day flow: 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts' Title 5 Official Insigection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .Sf- Property Address / ✓t C �l Owner Owner's Name information is Co 4 641 required for every page. City/Town State Zip Code Date of Ins ection B. Certification (cont.) Yes No ❑ zx" 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 cesspoollor 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. ❑ El Any portion of a cesspool or privy is less than 1'00 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. 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 Meet of a surface drinking water supply ❑ ❑ the system is within 200lfeet 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-09I08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts` Title 5 Official Inskp'ectiOn Form1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 5 A/ � Sf Property Address vt G Owner Owners Name q information is required for State Zip Code Date of Inspettioh every page. City/Town 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'i normal flows in the previous two week period? a 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) 2111-�❑ Was the facility or dwelling inspected for signs of sewage back up? [v]� ❑ 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? 2 E 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. Foriexample, a plan at the Board of Health. Part C is at issue h failure criteria related to a an oft e ❑ Determined In the field (if y approximation of distance is unacceptable) (316 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 151.203 (for example: 110 gpd x#of bedrooms): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System-Page 6 of 17 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 Property Address /- G Owner Owner's Name information is /� Oa 63S 3 0 required for �� t Ins tion 4 State Zip Code Date p every page. CityfTown D. System Information Description: /000 �A� oh rc AH�✓ / 6 X d Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes �[YNo Laundry system inspected? ❑ Yes LT No Seasonal use? P-les ❑ No Water meter readings, if available (last 2 years usage (gpd)): 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 Water meter readings, if available: ISMS•09i0B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Ins�p'ecto n Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address /— 0 ki / G u/ Owner Owner's Name information is required for Co 04 63S 3 �a / �/ every page. Cityfrown State Zip Code Date f Ins ection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: —� Was system pumped as part of the inspection? ❑ Yes &No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S stem: 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): t5ins-09/08 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y Property Address —,—/ ki G Owner Owner's Name / information is Cb 7'c.� , / / (,b�63S a2� required for every page. City/Town State Zip Code bate o Inspec on D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Id-9 3 Were sewage odors detected when arriving at the site? ❑ Yes El--No Building Sewer(locate on site plan): Depth below grade: feet Material of constructio;/4/0 ❑ cast iron PVC ❑ other(explain): Distance from private water'supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Mater' 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 cettificatCe) ❑ Yes ❑ No Dimensions: `J X 9 Sludge depth: 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 1 Commonwealth of Massachusetts' Title 5 Official In�sfp'ection Form Subsurface Sewage Disposal) System Form-Not for Voluntary Assessments Property Address v! G Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date/of Ins ection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness n l !/ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle D �14C. How were dimensions determined? -- Comments (on pumping recommendations, inlet and outlet tee or,baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): vi sM f yr 4 ril o/ -4v,-Je- c-4 4 v -h Vve Gi✓ti j 7iee— /✓1 010 N Co✓ ),�10 17 , 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 15ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts' Title 5 Official Insipection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ala Sf Property Address G / Owner Owner's Name (� information is cc,��,r oa 6 35 3 ;) // required for every page. Cityfrown State Zip Code Date of Ins ection 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 float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No M 15ins-09/09 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 Property Address / / 1/— Vt G �I Owner Owner's Name information is Co�U f Od6 3� 3 L11 required for every page. City/Town State Zip Code Date of Inspe tion D. System Information (cont.) Distribution Box (if present must be opened)(locate on site We 0 Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): �D �0/ s /V© z_eG Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamnber, condition of pumps and,appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachuseftst Title 5 Official Inspect G Formf Subsurface Sewage Disposal System Foram -Not for Voluntary Assessments Property Address / hG � Owner Owners Name information is rc, / 4tsp—ec oZ required for every page. Cityfrown State Zip Code Da 'on . D. System Information (cont.) 6�x Type: w/3 leaching pits, number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool b ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of p'onding, damp soil, condition of vegetation, etc.): A/6 14r)v?-C At.) d"4ir"_ 7� X1 f-e- 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 t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts MON Title 5 Official Ins1pection Form', Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 1/� G Owner Owner's Name information is 1�- 0d 6�?s �a required for �d � every page. Cityrrown State Zip Code Date of Insp ction 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.): l5ins-09/08` Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inespciti-on Formj Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owner's Name information is / f /�/7 CQ6-7s 3 �� required for ly every page. City/Town State Zip Code Date df Insp ction 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 boxe's below: ❑ and-sketch in the area below drawing attached separately { 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspec--ti-on Forml Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / ,Z— ✓1 G �l Owner Owner's Name information is 3>( A-2/// required for �f O`b every page. Cityfrown State Zip Code Date of Ins ection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 1150 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: jC' 4 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/06 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 Property Address / L pt c, Owner Owner's Name information is required for every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i-� Subsurface Sewage Disposal System Form Not for Voluntary _1\ssess,­_e-;s WO, S R / 7 ro_2 Property Address Owner Owner's Narne is rec-ired for even,page. City/Town State Zip Code D2fe D. System Information (cont.) Sketch Of Sewage Disposal System-, Provide a sketch of the,sewage dispcsan! sys'e— :es to at least two permanent reference landmarks or bench-marks. Locate all vvel!s v;:'�-;'n 00,'ce-e-t. Locate where public water supply enters the building. 01 OL C-1-/'G"r 5 4 guc-e, 60 ke'- / ','/ o -y 101- i13 - -2 6:, d3 4 ell, 10 j (7 ----------- h Commonwealth of Massachusetts Title 5 Official Inspecti ' n Form '01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Properly Ad ess Gi r� G Owner Ow is ame q information is rt NI 1 L required for T every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. In peC r: TTTfff �J only the tab key J to move your Qr� cursor-do not Name of Inspector use the return key. /(/ ii�/ 7 Co7ny Name n / .� 0 , X a Company Address 4s4ae7 ity/Town State � � � � Zip Code lephO 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 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaivation by the Local Approving Authority. /- 9-- 0 9 Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the.conditions of use at that time. This inspection does not address how the system will perform in thefuture under the same or different conditions of use. log t5inso•03/08 Title 5 Official Inspection For .Subsurface Sew@_e 7Espesal Svs'em•Pa_s 1 5 1 , Commonwealth of Massachusetts Gzffii. Title 5 official Inspection Form rl — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' Property Address z !�I Owner Own e' Nam�j �/f// ¢ information is required for � y�O / U r A OR 63 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.). Inspection Summary: Check A,B,C,D or E/always complete.all of Section D A) 7ss 'aes: 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic.tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven.distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewace Disoosa(Sys em-?_ze 7f Commonwealth of Massachusetts �l —m Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments MAC ��� ��/ • , v � Property Address / C, Pic., Owner Own s N me 2 nformation i /s ( ' 9— O 7 required for every page. City/Town State Zip Code Date of Inspection �. Certification cont. B) System Conditionally Passes (cont.): OX/ ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 00 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. t5insp•03108 Title 5 Official Inspection Form:Subsurface Sews^e O:spos=:Sys;am•?ace 3 Y- 5 Commonwealth of Massachusetts w=, W Title 5 Official Inspection Form l' I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Ow isla _ information is 6 �� �' 9 Q required for Will every page. City/Town State. Zip Code Date of Inspection Bo Certification (cons.) C) Further Evaluation is Required.by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ElBackup 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 u due to an overloaded or clogged SAS or cesspool ❑ �,/ Static liquid level in the distribution box above outlet invert due to an overloaded u or clogged SAS or cesspool ❑ ,�/� Liquid depth in cesspool is less than 6"below invert or available volume is less u than 'Yz day flow ❑ Required pumping more than 4 times in the last.year NOT due to clogged or obstructed pipe(s). Number of times pumped.: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water suppiv or tributary to a surface water supply. t5insp•03/08 Title 5 Official Inspection Form:Sc =_ur.'ace Sav;=__c Oisyosa'Svs:em• ace=c"5 Commonwealth of Massachusetts Title 5 Official Inspection Form I Jo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments //// • ,kj • ` / Property Address (17 ✓1 G 41, Owner Ow er's ame information is 9 required for —� every page. ity/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ � Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Rr� 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.] ❑ R/,-- The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined thafone 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 /V 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 El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone Il of a public water supply we!I 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. t5insp•03/08 Title 5Official Inspection Form:Sutrsura=e Sewage Disocsa S,sem•Pa_e 5 t5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owy�er's ame information is //� N t required for l�C> T every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No �❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ J?"� Were any of the system components pumped out in the previous two weeks? �❑ s the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ this inspection? . ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of 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 maintenance of subsurface sewage disposal systems? proper 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 u approximation of distance is unacceptable) [310 CMR 15.302(5)] t.5inse•03108 Title 5 Official Inspection Form:Suos.,race S=_wa^e Disposal Sysr=m• i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 S f— Property Address Owner Owner's Name information is 0 required for every page. City/Town state Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): ?? 3- DESIGN flow based on 310 CMR 15.203 (for example: 110,gpd x# of bedrooms): / Number of current residents: Does residence have a garbage grinder? ❑ Yes 2 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑ Yes No Last date of occupancy: Date /v Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203), Gallons perday(gpd) Basis of design flow (seats/persons/sq.ft. etc.):: Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): t5insp-03/08 Title 5 Official Inspection Form:Subsu-ace sewaoe.D!s?sa,s step-.•Pane 7 c' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurrf/acceSewage Disposal System Form - Not for Voluntary Assessments '2 J // Cl r h • S / Property Address G — Owner pwner's fya��e� w information is /v" /Y required.for H © every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: C?p 07- p Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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: g�! 0 — Uyht Were sewage odors detected when arriving at the site? ❑ Yes � Nlr� e t5insp•03/08 Tide 5 Official Inspection Form:Subsurace Sev._ce Disxsa Sr_iern•Fa'yE°c 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments J Property Address .OZ— � Owner Owner' IN C,1 information is required for N' every.page. City/Town State Zip Code Date of Inspection De System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction-. V cas/t 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.): Septic Tank (locate on site plan): Depth below grade: feet Materi construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank its metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- S_X Dimensions: a Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle M Distance from bottom of scum to bottom of outlet tee or baffle �o le- �G c%411ce How were dimensions determined. t5inso•03/08 Tiile 5 Official Inspection Form.:ScSs ece S=_v:=_;e pis Tsai Sys en•=_;e S cf?5 Commonwealth of Massachusetts- Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address 1-1 C, Owner Owner's Nr 4 �� �� / �_ 9- information is l/_0 N �— �.;'� �, 60 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid le Is as related to outlet invert, evidence of leakage, etc..): / /17 Oo C/ lv �.7/Oh . Grease Trap (locate on site plan): Depth below grade: feet Material of construction' ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): t5insp•03/08 Title 5 Official Inspection Form:5_bsurace S=-Wsce Dispcs2ii S,.sc=c•P=:=^C 'S Commonwealth of Massachusetts F Title 5 Official Inspection Fora I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 1 (02 Property Address. Owner Owner's Na e / information is a H�•T /j/�V Od&-75 g _0� required for / , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design FIOw: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert �— Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidenc of leakage into or out of box, etc.): /I/d Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes !!l No Alarms in working order: ❑ Yes ❑ No t5insp-03/08 Title 5 Official Inspection Form:Sebso.�ece Sews e Dispo of Sy •Page'':c; 5 Commonwealth of Massachusetts t =-:1—� `title 5 Official Inspection Form, �i �_ oI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address h Owner Owner's Name / information is required for �� w` J /"� every page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: —/ �(Ji' leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, tc.): /0 4/0 S f� �G` , , /lire . t5insp-03/08 Title 5 Official Inspection Forte:Subsur."ac=_Sawa_e D;soosa Svste^•pa— "5 Commonwealth of Massachusetts ;HI _ Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ZZ Property Address h Owner Owner's Nr-04MI information is required forOUG every page. City/Town State Zip Code Date f Ins ection . System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): !" Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of veaetation, etc.): t5insp-03i08 Title 5 Official Insoection Form:Subsu,iace Se:%.;=_Disaos2i S:s: Pa_=_'3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . c ( b- Property Address CI 0Gh Owner Owner's Name information,is ��O TH 0� required for every page. City/Town State Zip Code Date of Inspection ` l D. System Information (cont.) Sketch Of Sewage.Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �oy a G l7'/G r4r S CA Pe,. 113 _ 26, t5insp•03/08 Title 5 �Official Inspection Form:Subsurrace Sevrge Oiscosa:Sys e.^.•?ace? 0`?5 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / �G Owner Owner's Name �N i information is required for every page. City/Town State Zip Code Date of Inspection i I D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / Estimated depth to high ground water: feet Please in e all methods used to determine the high ground water elevation: Obtained from system design plans on record q _ If checked, date of design plan reviewed: Date ❑ Observed site (abutting prop ertylobservation 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 d cribe h w you established the high ground water elevation: 3 �P� ,h ii� ®� 147- -ki t5insp•03/08 Title 5 Official Inspection Form:Subsurece Sawsge Cs--osa S;;;e—•?__e'? 5 TOWN OF BARNSTABLE LOCATION to 1q SEWAGE # O(O/ VILLAGE CC' Jot.T ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.H 4A)1'CSCO SEPTIC TANK CAPACITY - /O a 0, C LEACHING FACILITY:(type) k & Ca (size) ®D err, NO. OF BEDROOMS J PRIVATE WELL OR UBLIC WATE BUILDER OR OWNERLf tbAJ / iyC . DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L/ i .r t � I�6 ►o 1 iN TOWN OF BARNSTABLE LOCATION LT l r, �(1� 5� SEWAGE # ''G VILLAGE_ 4�,AA, ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 160o - u LEACHING FACILITY:(type) 600 (size) C NO. OF BEDROOMS_ PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER ANC 9 AAQ Al DATE PERMIT ISSUED: IT, �AS 6- DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No F I � ' ���� v l A�' W U $/ o Fis........r . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...._.--......10(_10n........OF...A�s ........................... ApplirFation for 14spos al Works Tontrurtion ramit Application is hereby made for a Permit to Construct (V,")' or Repair "( ) an Individual Sewage Disposal System at i-------- --------------------•.--------.............. ........_. ..-----.......-••-••------ L ation-Add ess or Lot No. Owner Address W ���P ►rRr9 5 .................. ... ----------------•- Installer Address /' 20 Type of Building Size Lot_7�7}_ _ ....Sq. feet a Dwelling—No. of Bedrooms.............. ........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .............-........................................................................... W Design Flow...........5E:1.......................gallons per person per day. Total daily flow..... ......................gallons. WSeptic Tank—Liquid capacity` h i.60Cgallons Lengt _.(o..`___ Width. w__ Diameter________________ Depth!_�_(I_- '"- x Disposal Trench—No..................... Width--------_........... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........ Diameter._t_2,.'D_:'... Depth below inlet.._ `� ..... Total I hing area.2-4.5...sq. ft. Z Other Distribution box ( ✓) Dosing tank $4 Percolation Test Result Performed _.._ � ll ?__ -.a. J Test Pit No. I________________minutes per inch Depth of Test Pit___1 y ...._. Depth to ground water.._T_ ....... f� Test Pit No. 2...... .....minutes per inch Depth of Test Pit...).y.4........ Depth to ground water__fio.'��____ a' --•-------------------- •-;--------••- :1� ; 5 ..... ........ O Description of Soil------1.....��_ an- ... � . 51�. 5?4.. �— �-_ 1....... ;. ._t� S U ---•-•---•-•-•----•••-••••-••---------..�3(;-_A4 ..... ...�i cm�---------------------------W '?- ..........------------------------•----------------------_,----------------•----•----•------•--•---•--•------•--------------•-- UNature of Repairs or Alterations—Answer when applicable............................................................................................... •-------•-------------------•---........---•--•--...._..---•-------....----•--------------••--•---------•--------------------------.................................................................... Agreement: The undersigned agrees to install the aforedescribed nd ual Sewag posal System in accorda /en)��41 th the provisions of TITLE 5 of the State Sanitary Code Th d s fur er to place tr operation until a Certificate of Compliance has b n is oar of ea h. Signed•--•Z.- .............. ........ --....._•-----•• - 2_f 47 �� �D to I Application Approved By........ - - •-------•-------------- --•-----........................................ -----�---- _q. _,6__......_ Date Application Disapproved for the following reasons_....................................................................-........................................... -••------------------•---.........-------•---------------•-----.......---....-----------.._._..-----•----.._....--•-----...---------------•--------------=--=---•----------------•••-----•-..------•-•--- r Date PermitNo........... ----------•----•--------•---•-------•--• Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD <OFHEALnTH ®uR!U...................OF............ ''° '".... ...................................... Trrtifirahe of Toutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) by -------------------------------------------••-<......-v ?..f...........-•----•--....-•------•------._._....----••---------•-•-•-----•-•-------•- ....... _ UHsa -------Cam•-••- p ••--t has been installed in accordance with the provisions of T LE 5 of The State Sanitary Code as d scribed in the application for Disposal Works Construction Permit No._ _1?_"_jZ_Q, .......... dated....1 Z-.-I!/. ._�_ ______________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARAN EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...... ............................................ Inspector- •---=-----•-•---•-•------•---•---•-----•••--•-------- ............. :4p�R�1S • ch • No......................... FE$.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Works Tontrudion rrntit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at• e1 rk - - •- Location-Address or Lot No. ....r 4.c-- a .Owner Address ..........._.... Installer Address U Type of Building 1 Size Lot'-- ?! ---- feet Dwelling—No. of Bedrooms.............. .>........................Expansion Attic ( ) Garbage Grinder ( ) 4 a Other—Type of Building ---------------•--•-----•--- No. of persons...._.....Ie............... Showers ( -->--- Cafeteria ( ) dOther fixtures --------------- --•---••--•-..._..-------•--- --•--.---•••••--••--•-•••••--••-•••-------------......----- -- .._•------• W Design Flow...........L'`=_.._......_ti_..._.._�gallons per person per day. Total daily flow._._...�;_�.......................gallons. WSeptic Tank—Liquid capacity]_,!. _gallons Lengtli�.'.L,`...... Width±_.!.� `.. Diameter................ Depth:.'_)!..._. xDisposal Trench—No..................... Width=_._......_...._..... Total Length.................... Total leaching area....................sq. ft. j�: Seepage Pit No.......1............. Diameterl:!_..t�....... Depth below inlet..__ L.2._ Total 1 Ching area.: u__`/ ....sq. ft. Z Other Distribution box (✓) Dosing tank ( ) r aPercolation Test Results Performed b�_(!._a(-_:-_s,_V-)Ir!.1(to.-� :<�;eu�.(",_G? v��1.`` ?__._... Test Pit No. 1...._G".'.....minutes per inch Depth of Test Pit...�.��__-._.._. Depth to ground water..f6 ice........ (s, Test Pit No. 2......Z._.....minutes per inch Depth of Test Pit... .......... Depth to ground water.- ........... -------------------------=-------•----•-•---------•-----....--------.;................•.........................-----••--•----- D Description of Soil. ..... -_._-A ..........L r r `a....�v,.I-•-•-----•--•---•---- '�= 0_" t ;' `[C�.....................��.4.f v -------------------------------------•• 3! ._........................................................(1' 13 .L�--------...-------•------ W UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------•----------------------------------------------------------------------------------------------------•---•--------------------------...-------....-----------------.................--•---------• Agreement: The undersigned agrees to install the aforedescribed d dual SewaIth posal System in accorda ce ith the provisions of TITLE 5 of the State Sanitary ode T nd e f to place t e„ operation until a Certificate of Compliance has b e is e hoar o h 12 _ � [ C Signed ... .....................�!_::-J.._.... . O Application Approved By..-------- . _ ........:.........•- _...fZ _ e __...:_ Date-- . Application Disapproved for the following reasons:.............................................................................................................. ......................._.........................................-........................................---•---•--•---••-••-•--•------------........----------•----•------•--•---------.....-----•-•-- Date PermitNo................................................... - Issued....................................................... Date THE.-COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................................. O F...................................... (9rrtifiratr of Tontplianrr THIS IS TO CERTIFY., That the Individual Sewage Disposal System constructed) or Repaired by------------ ............................................................=------..........v :nr9:5-------......-------------------------_...._...---------------•-•-----------.._:_. SstZer at 9 i t�-•----------. has been installed in accordance with the provisions of T TI,�E 5 of The State Sanitary Code as 4escribed in the application for Disposal Works Construction Permit No ............ dated---1:7--- . ._g]__5............... THE ISSUANCE OF THIS'CERTIFICATE SHALT. NOT BE CONSTRUE®AS A GUARA14TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-----------•.............................•----.......=--•-•----•-----•---•_.._.. Inspector.................................................................................. THE COMMONWEALTH OF MASSACHUSETTS j BOARD OF_ HEALTH 77;�� , _/ OF..............:...............`..................._................................. S O Nob..................... FEE..._................... Disposal Works Tontrttrtion frrutit TA VIE r-4-S -� Permission is hereby granted....------------------------------------------...------ to Construct (\A) or Repair an Individuaall Sewage Dis osal System Tv I atNo. ............................._.-----------••--•�---5---...------ ----------....-------•-----------------------•--- ......... as shown on the application for Disposal Works Construction Permit Street PP p -12 2 J" 35�..._.... ��-�-----•-�y Dated_.--- - 1 Board Health DATE ` ''........f....<- ,...F--.... -.... FORM 1255 HOSES & WARREN, INC., PUBLISHERS _ SYSTEM SvcTEM PROFILE T TO SCALE 'NOT , � TOP-FDN. ; ' so. c3 FINISH GRADE OVER .!. '' FINISH GRADE EL . .o FINISH GRADE OVER s'y, ca ` FINISH GRADE OVER , .d.. DIST. BOX SEPTIC TANK i LEACHING PI T VARIES .,. a, t2 MA . . p. p ... . . :.a• . ° . .°.. ..d:.d. .. . ... ...o..o. .e. . ..•. o. .e.r. .e ,. � 3 of see 1/2 0... .O• �. .. •:�:'O':.0:..'•D.•..O.e p., .•:"••d: �. . d •d•'O,•e:e •:O .,. .• o,.a ..,.. .p. e..e.. . .. . . .. . . . . o. e.. e .. . PRECAST .GONG. ' OR p. ASHED 'PEASTONE ..o ,. .e. BRICK 6 MORTAR 3 1 OUTLET PIPE LEVEL TO 12" BELOW GRADE r•.: FOR 2 FT. MIN. .0,0..0 • o. •.D.•• :.,o.•o•.°•.'�:b.�o. 4•�:D e::o..;•o.;o..o a . 450 « . . o" . .. C. I. OR PVC. TEES . ,•., a 0. ¢ �•;:•,.•.�• .° .o "D' �' D e• a .. o .. 1 BSMT. FLR. . .. • . : ., G L L ON ... :o. - DISTRIBUTION BOX - EL . o. a INSTALL ON LEVEL BASE 3/4 - TO 1-1/2 ao ? a o. . . . . . .o D' CONCRETE T PRECAST a A PRECAST S e WASHED :a H- !0 REINFORCE® CRUSHED . CONCRETE p. d: S TONE . O O• •e4:0 .. o .d0. ..Q.p •o. s. ..d •.O.•O.• o. p,0; _ -, .Q o. o: a'. a o. o.°o•.o.•oQo'•• •o-Qo•:o•n•: :o. . o_, o•o:o• . L• - 7 �V REINF• ! SSEPTIC TANK � d� .o � ••�o. INSTALL ON LEVEL BASE NOTE. EXCA VA TE TO ELEV.` , 9 OR ar LOWER TO REMOVE ALL IMPERVIOUS MA TERIAL BENEATH THE LEACHING AREA -, REPLACE EXCA VA TED MATERIAL , WITH # CL EAN, CL A Y FREE SANG ,. C> EFFECTI VE DIM TER M A I N 5 7 R E T GENERAL NOTES L EA CHING PIT s .F � .�.r ' z o ` .� INSTALL ON LEVEL BASE i ss; 1. ALL ELEVATIONS SHOWN ARE BASED ON A S: tJ A4r E,C) ` 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON - --- --- _ OR SCHEDULE 40 PVC. O SERV TION PIT 3,. THE BOARD OF HEAL TH MUST BE NOTIFIED WHEN CONSTRUCTION IS COMPLETE PRIOR �— 62,3� 70' TO BA CKFIL L ING PERCOL A TION RATE. 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED MIN./IN. WITNESSED B Y* BY THE BOARD OF HEALTH' AND CAPE 6 ISLANDS /�PRECAST CONCRETE LEACHING PI r SURVEYING CO., INC. INS SHALL BE IN 5. MA TERIALS AND IN . , BAD. OF HEAL TH DESIGN DA TA �p N COMPLIANCE WITH THE STATE SANITARY - DATE. . - - = - - - AND LOCAL APPLICABLE CODE, TI TL E V F RULES AND REGULATIONS a sa NUMBER OF BEDROOMS • � : 6. NORTH ARROW 1'S FROM RECORD PLANS AND ,V> Z, .�„� � i Q , t GA RBA GE DISPOSAL f IS NOT TO BE ,USED FOR SOLAR PURPOSES a 7. FLOOD HAZARD ZONE C 4 DA IL Y FLOW . c GAL . 8. WA TER SUPPLY SEPTIC TANK REO 'D. co o GAL k, x 1000 GALLON SEPTIC TANK PROVIDED ✓© c�ca GA 4, PRECAST CONCRETE SEPTIC TANK 3 3 o GP LEACHING REQUIRED LOT 14 SIDEWALL AREA =_ iss� S. F. x.Rf S.F.X z. 5' GIS. F. _ ,�. .7 GPO Wit:, :� a s* ..- • c BOTTOM AREA r .� S.F. --- -� _. LEGEND i. S.F.X o G/S. F. _ �r GPD L EA CHING PRO VIDED " ' GPO s PROPOSED ELEVA TION w�. .- 3 a - ° —- EXISTING CON TOUR SINGLE FAMIL Y RESIDENCE f OGSERVA TION PIT ❑ DISTRIBUTION BOX F PROPOSED SEWAGE DISPOSAL .SYSTEM � LEA CHING PIT 29994 PREPARED FOR o o SEPTIC TANK 0 ,'- _ - MCSHANE CONSTRUCTION CO . Y✓ tRPI RESERVE LOT 14 MAIN STREET f� BARNS TABL E - CO TUI T -- MASS. PIPE INVERT ELEVA TION »'�, *� K' -3,5 DA PLOT PLAN " • CAPE 6 ISLANDS SURVEYING, INC. a SCALE AS NOTED P. O. BOX 334 j SCAL E• 117 . 4� L T HSE PL AN N. 7. TEA TICKET MASS�° �' , . M. SEC PCL O - �,