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HomeMy WebLinkAbout0061 MICHELLE AVENUE - Health W61 Michelle Ave Cotuit ' A= 027-063 r i Commonwealth of Massachusetts W Title 5 Official Insp ction Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 61 Michelle Ave M Property Address John & Martha Wheet Owner Owner's Name information is Cotuit w MA 02635 8/12/.11 required for every ' page. City/Town State Zip Code Date of Inspection- Inspection-results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information / on the computer, use only the tab 1. Inspector: key to move your r cursor-do not Ricky L. Wright use the return Name of Inspector key. _ B & B Excavation, Inc. rsb Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification 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 L 8/12/11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the,,inspector,:and the system owner shall submit the report to the appropriate regional office of the DEP ,Tl a 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 do ng idr_ss hqw xh`�system will perform in the future under the same or different conditions of use. I t5ins•09108 Title 5 Official Inspection Form:Subsurface wage Disposal System•Page 1 of 17 j � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :wM 61 Michelle Ave Property Address John& Martha Wheet Owner Owner's Name information is required for every Cotuit MA 02635 8/12/11 City/Town State Zi .. f page. P Code Date o Inspection B. Certification (cont.) Inspection Summary: Check A;B,C,D or E/always complete all of Section D A) System Passes: ® 'I have not found any information which'indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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* o�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):. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Michelle Ave 1M Property Address John &Martha Wheet Owner Owner's Name information is it t Cou MA * 02635 8/12/11 required for every II page. Citylrown State Zip Code Date of Inspection 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 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is required for every Cotuit MA 02635 8/12/11 page. City(rown 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 todetermine 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"No7 to each of the following for all inspections: Yes No ❑. ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters ❑' ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged,SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 61,Michelle Ave Property Address John & Martha Wheet' Owner Owner's Name information is .required for every Cotuit t MA 02635 8/12/11 page. Cityrrown State Zip Code Date of Inspection. B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ - ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ E Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ y 0 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.] ❑ F3 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 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 E] 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c,M 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is required for every Cotuit MA 02635 8/12/11 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 ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health r ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z ❑. 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? E •❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example:-110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is required for every Cotuit MA 02635 8/12/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? . ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a - 9 ( y 9- (gP ))� Detail: Sump pump. ❑ Yes ❑ No Last date of occupancy: current 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? El 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: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Michelle,Ave Property Address John &Martha Meet Owner Owner's Name information is Cotuit MA 02635 required for every 8/12/11 page. Cityrrown 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: 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 El .Single cesspool ❑ Overflow cesspool ❑ Privy El 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 l/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 ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Michelle Ave M Property Address John & Martha Wheet - Owner i Owner's Name information is required for every Cotuit_ MA 02635 - 8/12/11 page. Citylrown State Zip Code Date of Inspection D. System Information (co-nt.) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan):. `Depth below grade: 3'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other.(explain): >20' Distance from private water supply well or suction line: _ feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to bein good condition. No sign of leakage Septic Tank(locate on.site plan): Depth below grade: 2 feet Material of construction: ® concrete El 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: 52"X 62"X 8-6" Sludge depth: t5ins•09108 r Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 \- Commonwealth of Massachusetts. w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is required for every Cotuit MA 02635 8/12/11 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 3011 „ Scum thickness 4 4°, Distance from top of scum to top of outlet tee or baffle Distance from bottom,of scum to bottom of outlet tee or baffle 14" How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. Baffles present- no sign of leakage but pumping of tank is recommended. F Grease Trap(locate on.site plan): Depth below grader 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is Cotuit MA 02635 8/12/11t 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 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): F 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 l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form _ s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Michelle Ave Property Address = , John& Martha Wheet Owner Owner's Name information is, required for every Cotuit MA: 02635 8/12/11 page. CitylTown 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 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.): At time of inspection d-box appears to be in good condition-no sign of leakage or carryover 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.): 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 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is required for every Cotuit . MA- 02635 8/12/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 ❑ 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.): At time of inspection leaching appears to be in good condition. No sign of damp soils or hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate.on site plan): Number and.configuration„ Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09108 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form- Not.for Voluntary Assessments M 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is required for every Cotuit MA 02635 8/12/11 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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.): 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 -Commonwealth of Massachusetts F u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 61 Michelle Ave + Property Address John & Martha Wheet Owner Owner's Name information is required for every Cotuit MA 02635 8/12/11 page. Cityrrown 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 ~ 0 drawing attached separately lztra adds+to`n 1� f • i5ins•09/08 Title 5 Official Inspection forms Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is required for every Cotuit MA 02635 8/12/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: > 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date { ® Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: El Checked with local excavators, installers=(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing tfiis Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Michelle Ave Property Address John & Martha Wheet Owner Owner's Name information is.required for every Cotuit MA 02635 W12/11 page. Cityrrown 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 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE Q ! LOCATION �r G l�+=l/�` SEWAGE # /� , y / VILLAGE �� �U T ! ASSESSOR'S MAP & LOT O Z 1—y6 3 INSTALLER'S NAME&PHONE NO. l B , /I-S '-7 S" 7 SEPTIC TANK CAPACITY / LEACHING FACILITY: (type) ,�'� 7 ". — 4- L (size) NO, OF BEDROOMS 3 J BUILDER OR OWNER �fQ 1/A PERMITDATE: COMPLIANCE DATE: l 6 —/-q a Separation Distance Between the: Maximum Adjusted Groundwater Ta a and Bottom of Leaching Facility Feet Private Water Supply Well and Le ng Facility (If any wells exist on site or within 200 feet of ching facility) Feet Edge of Wetland and Leachin Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �j r TOWN OF BARIv'S'TABLE LOCA tiONi G je ���`,_ ` SEWAGE # Ll VILLAGE C4 (U o r ASSESSOR'S MAP & LOT 0_Z —C*3 INSTALLER'S NAME&PHONE NO. /A�'S S t ? LL F 2 4 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ��- ®9 —�- L (size) NO.OF-BEDROOMS BUILDER OR OWNERTC0 L 11A PERMITDATE: /b—/— 19 1�i COMPLIANCE DATE: l G —dA,(15 Separation Distance Between the: Maximum Adjusted Groundwater Ta e and Bottom of Leaching Facility Feet Private Water Supply Well and Le ng Facility (If any wells exist on site or within 200 feet of 1 ching facility) Feet Edge-of Wetland and Leachin Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �-- { \1 � � . � �. ___, � � � j _ �� ® F d � e �, Er No. Fee a^ $5 0 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpprication for Migogar *pgtem Conztruction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) El Complete System El Individual Components Lg� M c tion Address o of No. Owner's Name,Address and Tel.No. ichele Ave . , Cotuit , MA Robert Gonella Assessor's Map/Parcel 06 2 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville , MA e of Building: g• Dwelling No.of Bedrooms 3 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 Sand. Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system. D—box and. 2 leach chambers . 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 Envir nmental Code d not to place the system in operation until a Certifi- cate of Compliance has been issued by this ffiyA oJOe-alth.,, l Signe f J0 Date !��`"�`• Application Approved by 0 Date Application Disapproved for the following rea n Permit No. o Date Issued C. --� $50 Nor' ' , '3? Fee THE COMMONWEALTH OF MASSACHUSETTS ~ Entered in computer: Yes .- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migogar 6pgtem Congtruction Permit Application for a Permit to Construct( )Repair(X )Upgrade( . )Abandon( ) ❑Complete System ❑Individual Components a L•c tion add es of No. Owner's Name,Address and Tel.No. 14T�ci �le Ave . , Cotuit , MA Robert Gonella Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. rt 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 . ) 4' rT Size of Septic Tank Type of S.A.S. Description of Soil Sand X-1. 4 R� Nature of Repairs or Alterations(Answer when ap licable) Title-5 E leach s Y , m. D-box and 2 h ach chambers . Date last inspected: Agreement: 1l 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 Envii• nmental ode! nd not to place the system in operation until a Certifi- Cate of Complia ce has been issued by this d ealth. / �J (Signe / n Date Application Approved by Date Application n Disapp'roved or the following ra Permit No. Date Issued --———————== �——_———- THE COMMONWEALTH OF MASSACHUSETTS Gonella BARNSTABLE, MASSACHUSETTS THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 61 Michelle Ave . . Cot' it has n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ,/0 —r—9 Installer Wm. E. Robinson Sr. ; Designer The issuance of this permit shall not be consttt�fi`e/d as a guarantee that the syst in ill function a designed. Date l /— InspectorC ,1 Ile No. � Fee $5 0 f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH!DIVISION - BARNSTABLE., MASSACHUSETTS Gonella Miom ar *pgtem Construction 3permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 61 Michelle Ave . , Cotuit 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. V.- Provided:Constru do mus be completed within three years of the date of it. l Date: r Approved by 1�X j 6 A i '� Wit/✓ �L� 1/b/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) y IWilliam E .- Robinson,SAereby cerifY that the app lication for disposal works construction permit signed by me dated 16 -1- 92 concerning the property located at 61 M i h P l l e Ave - , C of uit-, 94 meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. ' The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. y �iere are no wetlands within 100 feet of the proposed septic system The are no private wells within 150 feet of the proposed septic system • Pere.is no increase in flow and/or change in use proposed • There are no variances requested or needed. © The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable) If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen().1) feet above the maximum adjusted groundwater table elevation, Please complete the following. y A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the MAX. High G.W. Adjustment. = .43 DIFFERENCE BETWEEN A and B —1 SIGNED : r- ` DATE: 16 [Sketch proposed plan of system on back]. q:health folder:Bert '{ Q ` � .. `� a. / ' .\ � - �-J N� , C i 1 v = _ Com.1102XN EALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF E:�'VIRONME\TAI AFFAIRS r_ DEPARTMENT OF ENMONMENTAL"PROTECTION ONE WINTER STREET, BOSTOI; Dom,021OF i61�o 292.550o TRUDY CORE Secretan ARGEO PAUL CELLUCCI DAVID B. STR:.HS Governor Comnussioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prop"Address:61 Michele Ave , Cotuit , -'Ml�lameofOwner Robert Gonella Address of Owner: 0 B OX F 0 s t e ry i l l e i MA Date of Inspection: Name of Inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved systerr2 inspector rsuant to Section 15.340 of Title 5 1310 CMR 15.0001 Company Name: Wm. E . Robinsoneptic Service MaBingAddress: PO .Box 1089, Centerville MA Telephone Number: a 7 8 0_ CERTIFICATION STATEMENT; I certify that 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ' _v Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: `�/ i Date: The System Inspector shall submit a copy'of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be,sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS OCT 15 1999 TOWNOFMSTABLE HEALTH DEPT, A9 revised 9/2/98 Page IofII %j ✓—ied 0n Rec,lcicd Papa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) "roperty Address: 61 Michele Ave , C otuit Jwner: Robert "onella Date of Inspection: INSPECTION SUMMARY: Check(A�, C, or D: A. SYPASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: a B. S STEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon ompletion of the replacement or repair,as approved by the Board of Health, will pass. Indicate no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. yen The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank whether or n I p of metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system•will pass inspection if(with approval of the Board of y Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corttinued) Property dd ss: 61 Michele Ave . , Cotuit Owner: o T: t Gonella r P Date of inspection: / 6 - 1-9 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 the ublic health, safety and the environment. 1 S TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINE S IN ACC ORDANCE CCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS 1i10T FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYS M WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNC IONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. . The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 31 THER • c ' S revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (correnued) Property Address: 61 Michele Ave . , Cotuit owner: Robert Gonella Date of Inspection: 6 0„ P D. SYSTEM FAILS: You must indicate either"Yes" or "No" to each of the following: I ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this The Board of Health should be contacted to determine what will be necessary to correct the failure. de ermination is identified below. T Y Yes No Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. GE SYSTEM FAILS: You mu indicate either "Yes" or "No" to each of the following: he following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public he Ith and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The ow r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office o e Department for further information. revised 9/2/98 Pagc4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Prop"Address: 61 Michele Ave . , Cotuit Owner: Robert Gonella Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the.following: Yes , No Pumping information was provided by the owner, occupant,or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection, r As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up: _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)1 , The facility owner (and occupants,if different from owner) were provided with information on the proper tnaintanaaca of SubSurface Disposal Systems. revised 9/2/98 page 5orll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION sroperty Address: 61 Michele Ave . , Cotuit Owner: Robert Gonella Date of Inspection: FLOW CONDITIONS RESIDENTIAL': Design flow:�g.p.d./bedroom. Number of bedrooms id Number Number of bedrooms (actual): Total DESIGN flow"' Number of current residents: Garbage grinder(Yes or no):_ Laundry(separate system) (yes or no)://0: If yes, separate inspection required Laundry system inspected (y or no) Seasonal use (yes or no): PL s Water meter readings, if available (last two year's usage(gpd): 1998 76, 000 gal . Sump Pump (yes or no): Lest date of occupancy:- 1997 80, 000 gal. COMMERCIALIINDUSTRIAL: Type of esta lishment: Design flow: d ( Based on 15.203) Basis of desi n flow Grease trap p esent: (yes or no)_ Industrial W to Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water mete readings,if available: Last date f occupancy: OTHERii(Describe) Last da$4'of occupancy: GENERAL INFORMATION PUMPING RECORDS �gafce of information: System pumped as part of inspection: (yes or no)-6&-- If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM ptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/9E Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) srop"Address: 61 Michele Ave . , Cotuit owner: Robert Gonella t Date of Inspection: BUILD G SEWER: (Locate site plan) Depth bel w grader Material o construction: cast iron 40 PVC other(explain) Distance f om private water supply well or suction line Diameter Commen : (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: L-concrete_metal_Fiberglass _Polyethylene:_other(explain) If tank is metal,list age_ Wage confirmed by Certificate of Compliance_ (Yes!No) Dimensions: h at •� Sludge depth: C'J Distance from top of sludge to bottom of outlet tee or baffle:, Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: � 1 > Distance from bottom of scum to bottom f outlet tee or baffler J How dimensions were determined; 'omments: .(recommendation for pumping, condition of inlet and outlet.tees orbaffles, depth of liquid level'd relation to outlet invert, structural integrity, evidence of I akage, etc.) /b GREAS TRAP: (locate on ite plan) Depth belo grade:_ Material of onstruction:_concrete metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thick ass. Distance fr m top of scum to top of outlet tee or baffle: Distance fr m bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comm ts: Ireco endation for pumping, condition of inlet and outlet tees orbaffles, depth of liquid level in relation to outlet invert, structural integrity, evident of leakage, of revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION Icorronued) ' i,rop"Address: 61 Michele Ave . , Cotuit Owner: Robert Gonella Date of Inspection: TIGHT R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on ite plan) Depth belo grade:_ Material of onstruction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flo gallons/day Alarm pre ent Alarm lev I: Alarm in working order:Yes_ No_ Date of revious pumping: Comm ts: (condi ion of inlet tee, condition-of alarm and float switches,etc.) DISTRIBUTION BOX:.— (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note it level and distribution is equal, evidence of solids carryover, evidence f I akage into or out of box, etc.) - PUMP CHAM ER: (locate on site plan) Pumps in wor ing order: (Yes or No) Alarms in wo ing order(Yes or No) Comments: (note conditi n of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION(corttinued) lrop"Add►ess: 61 Michele Ave . , Cotuit Owner: Robert Gonella Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: . Type: leaching pits, number:_ leaching chambers,number:— leaching galleries,number:_ leaching trenches number, length: leaching fields, number, dimensions: i overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydrau c_fHilure, level of p nding, damp spil, condition of vegetation,•etc.) CESSP0 L'S_ (locate on s e plan) Number and c nfiguration: Depth-top of li uid to inlet invert: Depth of solids layer: )epth of scum ayer: Dimensions of c) sspool: Materials of con;truction: Indication of gro ndwater. inflow cesspool must be pumped as part of inspection)' Comments: (note conditio of soil, signs of hydraulic.failure, level ofponding, condition of vegetation, etc.) PRIVY:_ (locate on sit plan) Materials of c nstruction: Dimensions: Depth of solid " Comments: (note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised; 9/2/.y8 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Noperty Address:61 Michele Gone lla Jwner: Robert Gone lla Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public.water supply comes into house) L r , sb � n b 99-(� revised 9/2/98 Page 10of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) roperty Address:61 Michele Ave Cotuit Owe: Robert Gonella Date of Inspection: 16 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.,) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed revised 9/2/98 Page 11of11 L.0 CATION SEWAGE PERMIT NO. V VILLAGE I N S T A LLER',Sl NAME ' i ADDRESS � TI cc kE�1 D U I L D E R OR OWNER NJ DATE PERMIT ISSUED !2-s- ,,?zv DATE CORIPLIANCE ISSUED f2�i-g9 . , ��o C' ".. —`. '� y q^ s NO.H.1-.�. ...d THE COMMONWEALTH OF MASSACHUSETTS BOAR O Z � I� .... ......... ............OF. --..._.--...... .............................. ApplirFation for Kh"atiFal Works m3trn.rtion Vrrutit Application is hereby made for a Permit t Construct ( or Repair•( ) an Individual Sewage Disposal System at: / ............................ _ ... � Location-Address ! . .��� �^„� Jsot No. / ,/�' ow ress a .....-- ................................. ........A. .. ...... . ....-----•--•--------.._................._........... Installer 1 Address Type of Building Size M. .Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building No. of persons............................ Showers — Cafeteria a Other --•---- -------------- -•---•----•----..---•----------•---------- W Design Flow............ .. ........................gallons per person per day. Total daily flow.._....�Z.Z.....................gallons. WSeptic Tank—Liquid capaci ,M_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width Total__.....__.._... Total Length......... Total leaching area .. __._........sq. ft. Seepage Pit No._...�_____________ Diameter.._..d�.......... Depth below inlet.......k.......... Total leaching ar;a.q q. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-________---_-_.---_-__. f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------- ff ��... -----...•-.--.-•----• --------- -------------------------- --•-•--•------•--------------•---.------------••-----•--. O Description of Soil. ,!:Z.. :1,..—_r9�...�".A___.._ . x --- ------------ ----- Vw -------••--•..............6 ••-•---•-•--...... -------- -------------------------------------------•---------•---•--•--------•-•--•--------- 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 TITIS 5 of the State Sanitary Code— The ndersigned further agrees not to place the syst m in operation until a Certificate of Compliance has be i b e board of health. Brie �� -• ...... .---•-- ------. ApplicationAPPro ••--•--- •• -----•---------------------------------------•....•------------------------------ ---------------- -Date Application Disapproved th ollowing reasons--------------------------------------------------------------------------------•--------...---•------.....•••••. ...........................................................:..........................................................--....•--•--•-•-----•--•----•----------------•-•--•-•----•-•--•----•••-•--•••••••-- Date PermitNo......................................................... Issued....................................................... Date No.:................... Fps.. .�.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF fftLTH Appliration for lliivosal lvork.5 Tonitrnrtion Famit Application is hereby made for a Permit,to Construct V or Re air= an Individual Sewage Disposal PP Y � � ( ) P ( ) g _p System at: l /'L ;� �,� r t �,•ayp t gg $f �� �. Location-Address .,�� � �� � � ��^}j�_� 3 e ��t-No. W ," .0...O wnr f! /f Atlfiress ', ,.ei'. !} ...._K �°'�='•-�`�"°zz ...............................:. f...�. Installer ress � Type of Building Size Lot..�'-`sw j.!' ,J..Sq. feet �.� Dwelling—No. of Bedrooms...........: ...........................Expansion Attic ( ). Garbage Grinder ( ) Other—Type e of Building No. of persons............................ Showers �4 YP g ----•-•-•---------•--------- P ( ) — Cafeteria04 ( ) Other 4xtWw ----------------------------------------------•------------.------------------------......--•-------------...........--------........---------------- n Flow � DSestic Tank—Liquid Li•-uid--ca--aci --�;...' alloons per person per day�idth daily-flow Diam .....................gallons. W P q P -'��-g Diameter................ Depth................ Disposal Trench—No............... ..... Width.................... Total Length.................... Total leaching area.... ..-_ ...sq. ft. Seepage Pit No.... .............. Diameter__._.: .__...__ Depth below inlet____._�:�.._._..... Total leaching area'���`__...._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY........................................................................= Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------.------------ Depth,to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to'ground water........................ a ---••------ •-----------•--------------------•- O Description of Soil.&,nz _.... .. _r -f`! �- x •---------------------------------------•- U t t 1 .� �•p ---------------------•--•-----•••--....._....._ ..............................................................•...................................... 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 TITLE 5 of the State Sanitary Code— Th undersigned further agrees not to place the Sys m in operation until a Certificate of Compliance has be n i su d b the board of health. Signed .•-:•......:. ----------------- --- •--•• -- Application ApproveBY- ------------•-----.. + Z' . .. ...--..---�...... fa ate Application Disapprove if or e following reasons:.............................................----------•--------------------...-----------------.....--------- ......-•-••----•----•---•-----••--------------•••----••••---------•---•••....--•---------------•-••....---•..................-•-----•-••--•••--••-••------••-••--••••-••••---------••-••--•••----------- Date PermitNo--------------------------------------------------------- Issued----------------------------------------------.......... Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD, F Hr_j-Ty, r.... !'!...........OF.......a,!q�fe ....,,/.,.. .... ............. Trrfifirate of Tontpliatta THIS IS TO CERTIFY That the widugal Sewage Disposal System,constructed ( or Repaired ( ) by---... / at.--•••----•--. -•-l! ..................... f°- G��f- ------�"------ta� z`��1 ° f .................... has been installed in accordance with the provisions of TLP,,�pf The State Sanitary Code as described in the application for Disposal Works Construction Permit N ......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION MTISFACTORY. / DATE--------•-----------•--•...................... . . ---...-------- Inspector-------- �`............................................................ THE COMMONWEALTH OF MASSACHUSETTS ,,�''�., BOARD -.6F HEAL H . °'xJt.......OF........ A4 A No......................... FEE.•==-.:............ �li��rla��l, rko �o ��r to ernti# - Permission is eby granted.; _� � to Construct ( or Repair an d vldu Se e D> peal Sy tem , !� "' ' at No........ Street as shown on the application for Disposal Works Construction Permit No..... ......... Dated.......................................... ---------... -------- ............................................................ Board of Health DATE.................... '= = ........................... FORM 1255 A. M. SULKIN, INC., BOSTON FAM Y BEORnOM 1.10 GAQB46Ev6PJWDF-9Z p/aILY FLOW .. IICU A 3 s 730G,P. SEPTIC, TASK = 330x15D% s A9ib,P. q �l %CP u5C- %000 GA%-. 015Po5AL PIT usE 1000 GAL. d S 1 DG.vdA�L A2Cla = 1 go S.r: i5o 5.F X 2.5 r 'T TOM AREA o s r--? G.p� i�P...c� L . � 80 �� Ae 'Ig�Q S: ��) �SC F.� x 1• o G• 5'o G.P o'T oT A t.. DESIGN = •4 2 5 (,.P. D• O 74PTAL- DA I►-Y F%-oV! \coo FaL PFIZCOLA.TION RATES I''IN 2MIN OP-LE55OCR �>pro`` �`•��'t , L, I T \.:j ZE Ic NY E d No r I To P FNu= C) C loco INv. 1I _ Sc.V�r ul�I 015T. GIN 1 GAL.. q(v•�, _.2 BUX - PT {L�G -TANK 96 I 9G•0 D r"►�T INV. INv. 1� D WAWr.D el t,ToNicc , GE2TIFtGD pI PLAtJ I. L PROFILE L044-TI01J', �- Turr L w No SCALE ScALE,� � � o� �ATEt � , �e '8a � 1 CE czTIFY THAT 'THE (J� � �.rC SNowN I NEszSoW COMFLY5 WMATHE SIo1rLINSr AWD 5E7r5.CK 2E6Q0�1,,P�-� eMENT� OFT44 { "SOWN OF ��...FfhaxC_ AND 1r, NET ILOCp.TE D W ITN11J TNNIC;8-OOD PLL►.I D AT E BAXTE2e IJYE INC. RLS6 I VT 6Q6•D'►AN Ds u r TIa►S PLAN 15 NaT 4n5C_p �b N os'rE¢.vILLJr • MA55 I Iu5TRuMBN-t 5VeVe-Y F- -rNE n1-FSET5 6uouL3) t No-T ('>� VSEDTo t7ETE•R/nINE L.oT 1 INE.�j APPLICA►J"r �� ��