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Home My WebLink About0192 MOORING DRIVE - Health i 192 Mooring Drive Cotuit A= 024-113 Commonwealth of Massachusetts Al f Title 5 Official Inspection Form L0111yi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,M 5V•,r 192 Mooring Drive Property Address Chris Papadellis Owner Owner's Name --- information is required for Cotuit _ MA _ 02635 _ October 5, 2012 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 A. General Information forms on the V computer,use Inspector: 5 only the tab key 1. 0 to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return — key. Ready Rooter Excavating .Company Name * P.O. Box 89 Company Addres—s - Forestdale MA city/Town rown state 02644 Zip Code 508-888-6055 SI 12843 Telephone Number License Number r 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 i smection. The inspection was performed based on my training and experience in the proper function and rnafntenanceZf one sewage disposal systems. I am a DEP approved system inspector pursuant iSection5'.340 Title 5 (310 CMR 15.000). The system: c Z ® Passes ❑ Conditionally Passes ❑ .Fai1. co M �v ❑ Needs Further Evaluation by the Local Approving Authority can tad --��,�� _ October 15, 2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11/10 Title 5 Official In ctio -orrn.Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 192 Mooring Drive Property Address - Chris Papadellis :3 Owner Owner's Name information is required for Cotuit _ MA__ 02635 October 5, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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" ,N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years o * or the septic tank (whether metal or not) is structurally unsound, exhibits substantial i Iltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is eplaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspe ion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan is less than 20 years old is available. ❑ Y ❑ N ❑ D (Explain below):- t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 i i 1 . 'Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Mooring Drive Property Address 4 Chris Papadellis Owner Owners Name information is COtUIt required for _ MA 02635 October 5, 2012 every page. City/Town State Zip Code Date or—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 lev ed 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 Re mired by the Board of Health: ❑ Conditions exist which r uire further evaluation by the Board of Health in order to determine if the system is failing to rotect public health, safety or the environment. 1. System will pas 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ ,•'' 192 Mooring Drive Property Address Chris Papadellis Owner Owner's Name information is COtUIt required for _ MA _02635 _October 5, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water suppl or tributary to a surface water supply. El The system has a septic tank a d AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic to and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank an SAS and the SAS is less than 100 feet but 50 feet or more from a private water supp well". Method used to determine dis rice: ** This system passes if the ell water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates sent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. . 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an.overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged'SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert.or available volume is less than Y2 day flow [Sins•11/10 P Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 i .1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Mooring.Drive Property Address Chris Papadellis i Owner Owner's Name information is required for Cotuit _MA 02635- October 5, 2012 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) t - Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped, ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes 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.] 0 ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑, ® 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 k r ❑ ❑, the system is wit n 400 feet of a surface drinking water supply ❑ ❑ the system is ithin 200 feet of a tributary to a surface drinking water supply ❑ the system s located in a nitrogen sensitive area (Interim Wellhead Protection Area — I A) or a mapped Zone II of a public water supply well If you have answered "yes"t any question in Section E the system is considered a significant threat, or answered "yes" in Sectio D above the large system has failed. The owner or operator of any large system considered a signi cant threat under Section E or failed under Section D shall upgrade the system in accordance wi, 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 , F • Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �„ ,•'' 192 Mooring Drive . Property Address Chris Papadellis Owner information is Owners Name required for Cotuit MA 02635 October 5, 2012 every 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 t ® ❑ Pumping information was provided by the owner, occupant, or Board of Health El ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 'Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD t5ins•11110 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Mooring Drive Property Address Chris Papadellis Owner Owner's Name information is required for Cotuit __ MA _ 02635 October 5, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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? El Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2011= 312 GPD* Detail: ' 2012= 383 GPD* *High water usage during summer months due to irrigation. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: ' Design flow(based on 310 CMR 15.20 Gallons per day(gpd) Basis of design flow (seats/person q.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tan present? ❑ Yes ❑ No Non-sanitary waste disc rged to the Title 5 system? ❑ Yes ❑ No Water meter readings/if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Mooring Drive Property Address Chris Papadellis f Owner , Owner's Name information is required for Cotuit MA 02635 October 5;2012 every page. Ciffown 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: No previous record found ,Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance 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): t5ins•11/10 » Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page a of a Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''� 192 Mooring Drive Property Address Chris Papadellis Owner Owners Name information is required for Cotuit MA 02635 October 5, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Septic tank and 1 st pit installed 1981. 2na pit added 12/8/1988. Certificates of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade:.} ' TT' feet Material of construction: ❑ cast iron ❑`40 PVC ® other(explain): ABS Distance from private water supply well or suction line N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: . 2'6 feet Material of construction: ® concrete ❑ metal [--]'fiberglass ❑ polyethylene ❑ other(explain) 1 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5'X 5'X 4.5' 1000 gallons . Sludge depth: 30r t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s. 192 Mooring Drive Property Address Chris Papadellis Owner Owner's Name x information is required for Cotuit MA_ 02635 October 5, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Septic Tank (cont.) 321r Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1/21r Distance from top of scum to top of outlet tee or baffle 800 14" Distance from bottom of scum to bottom of outlet tee or baffle — How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet ABS tee and outlet concrete baffle in place. Liquid level at outlet invert. Tank pumped and cleaned after inspection. Risers bring cover within 6" of grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: . ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum o top of outlet tee or baffle Distance from bottom of'scum to bottom of outlet tee or baffle" Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 .Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 192 Mooring Drive Property Address Chris Papadellis Owner Owner's.Name information is required for Cotuit MA. 02635 October 5, 2012 every page. Cdy/Town State Zip Code Date of.lnspection 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: El Yes ❑ No J Date of last pumping: ' Date Comments (condition of alarm and float switches, etc.): z- *Attach copy of current pumping contract (required). Is copy'attached? ❑ Yes ❑ No t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 i 3 Commonwealth of Ma ssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V Svc' 192 Mooring Drive _ - Property Address Chris Papadellis Owner Owner's Name information is COt_Ult required for _ _MA 02635 October 5, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): On 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.): One inlet, one outlet. No solids carryover. No high water staining over outlet invert. Riser brings cover within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pum chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: [Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 "Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Mooring Drive Property Address Chris Papadellis Owner Owner's Name information is required for Cotuit MA 02635 every page. City/Town — October 5, 2012 D. Syste State Zip Code Date of Inspection m Information (cont.) Type: ® -.leaching pits number: 2- 1000 gal ea. w/stone. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level in 1 st pit 6"off base of unit. High water staining 3' below invert. 2no pit dry. No sign of high water staining. No sign of past hydraulic failure in either pit. 2nd pit added in 1988 for bedroom addition, not for 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection p on Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .It, 192 Mooring Drive Property Address Chris Papadellis Owner information is Owner's Name • - required for Cotuit MA 02635 every page. Cityrrown October 5, 2012 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.): Privylocate ( on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, 'gns of hydraulic failure, level of ponding, condition of vegetation, etc.): A p t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 TOWN OF BARRNSTABLE LOCATION SEWAGE �P VILLAGE_(�fE7�-c ASSESSOR'S MAP&PARCEL SEPTIC TANK CAPACITY LEACHING FACILITY.(type) ecs��, 5 (size)a- Zc�oe ja.Ak, e.J, NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility s Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within f 300 feet of leaching facility) Feet FURNISHED BY AN �� - 30' S,so�s-e zrcc,\�. � o O 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 192 Mooring Drive Property Address Chris Papadellis Owner Owner's Name _ s information is Cotuit required for MA 02635 October 5, 2012 every page. Cdy/Tovvtl State Zip Code C e of Inspeaion D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached'separately i � O 0 3 t5ins•11110 i.. Title 5 Official Inspection Form:subsurface sewage Disposal system-Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Mooring Drive Property Address Chris Papadellis Owner Owner's Name information is required for Cotuit every page. Ci Fown MA 02635 October 5, 2012 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high groundwater: '5 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: May 24, 1979 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole in 1979 to 12'found no ground water. Base of 2na pit 9'+- below grade. Slope to side of property drops below base of SAS. Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments b s••''r 192 Mooring Drive Property Address Chris Papadellis Owner Owner's Name information is required for Cotuit MA 02635 October 5, 2012 every page. City[Town 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 e t51ns•11l10 .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNS TABLE r LOCATIONCZ I SEWAGE Co� VILLAGE Qk ASSESSORS MAP & LOT T INSTALLER'S NAME ru PHONE NOF I K l '�� Z - . SEPTIC TANK CAPACITY 0 At___� o. LEACHING FACILITY:(type) 1`'c', ize) NO. OF BEDROOMS PRIVATE WELL f�R P[iBLLC WATE t BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 t � "1 � ' �_ . G TION Not SEWAGE PERM T NO• ` LAGE oVW 113 INSTALLER'S NAME, i ADDRESS t U I L D E R OR OWNER DATE PERMIT ISSUED ��° DATE COMPLIANCE ISSUED biz c G o nr�r No.__ .:kO' FEB.• •�5 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH - OF......... . ApplirFation for iiiiv.aiaal Works Tonstrurtion rumit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: .-- ..` . _ _._fit s�_ .^. ..-: -------,--�. 1�- - ---- --------------------------------1-13.......................................................... - Loc ion,-Address y fi ® or Lot No. lnx��.._.._.. ....................... . s. ----o.L�EL. ._._....3Hfa.�JJ_!Y �d9+J_ f ^.. � Owner Address r��.t"1. ..........11 n?d!19_t..SW........................................... ......................._.......................................................................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.......... ..............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Buildin a g -------------------•-------- No. of persons............................ Showers ( ) Cafeteria ( ) d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow...................=........................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_______---_..__- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date-------------------------•-------•----- a - 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-_____---.._--.-________ 1�1 --_-•_______________________•_____-____-._.____-_.---_--_-_-_-_----.._..-.----..-.-.---.--_-.-.--.------------------------------------------------------_-- 0 Description of Soil....................................................................................................................................................................... x ---------------------------------------------------------------------------------------------------------- - - ------------------------------ V Nat e f;.�epairs or. te_ations—Answer when applicable_..'' _ _. ��_ ._._ s�1 � .. .......................... .._.l �- i .------------------•----•-------•----------•---•----------------------••---......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha ee 6*ssued b of health. Signe •. --- .... Date Application Approved By.. ...............--•------------ ..-------- Date Application Disapproved for the following reasons:.................................. -----•--------•-•-•----••---•-•--•------•................ ......•---•--- ...............................----•---••----------------•---••-•----••--------•-----•---...---._...•••... ....•-••••----•----••------------•---•-----••--------••--••••-••----••......•-•-••......----- �} Date PermitNo........Q. ................7---------------------- Issued........----------••--------•--•---.....-----•--•------ Dat THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................I................... . Appliratiun for Dispas al Workii Tonutratrtiun rranit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................-................................................................................ ...........-•-••---•-•••---••••-•-...........-•••--....••••---••.........--••-----•--•---•-------. Location-Address or Lot No. ......-•---•--------...................•----------.....------••----............•................. .................................................................................................. Owner Address W Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ---------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___---____._._-___-__-. fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to-ground water........................ --•--------•------------•-----•-----••--------•----•--------------•---•-----•----------•----•-•--•--......................................... -----------•---- 0 Description of Soil....................................................................................................................................................................... x W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------•••------•--•---•----•-•------•-•--------•.......-----•---•-•--------••-••---------------•--------•---•-•-------•---•••--•--••---------•------••-•-•---•...... Agreement: The undersigned agrees to install the aforedescribed .Individual Sewage Disposal System in accordance with the provisions of it.IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed....................................................................................... Date Application Approved By. _._ `. ....... ................... ------- f J_ 7lte- Applieation Disapproved for the f ollowing�easons:-----•---------•.......................•-•--•---------••-----------------------•-I----------------......------._ ..............................••.....---•...-----------------...---------------••-------------......_---- Date Permit ------------------------- Issued----------------------------------------•--------------- L�-. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF................... w 1 a1 .................... (Irrfif iratr of 6�tp iFanrr THIS IS TO CERTIFY V��e Individual Sewage Disposal System constructed ( ) or Repaired ( ) by .._...... ........................................... . at ` �------------ ----------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TI T IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No '. c ...... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ---� DATE.....................l.dZ` ............................... Inspector................. ... = ---------------------•----------••---_------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (f C/I�L- Y d C�vyv1-0,4' ............... ..................OF.......... NO.. FEE................ ...... 'Disposal T.1$ nuir iun rrnti� Permissionis hereby granted........................................................................................................................................ to Construct ( -Ryay ( ) ' IndividuallpS�e,Arage�Dis oral stem at No............................. ... XG �..._..r v %Street as shown on the ap lication for Disposal Works Construction Permit No---------------- -- .. t ) 1 Board of Health DATE------• --- -•�----- •- •---•-----•--------•----•--------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r IJ0..7 .... y 1g Fizz............... . THE COMMONWEALTH OF MASSACHUSETTS BOA-RD OF HEALTH ,� ...................OF... ..---..._.....--------•----------------;-...........------------. I Applir�a#ion .for Disposal Works TonstrUr#ion ramit Application is hereby made for a Permit to Construct (X or Repair ( ` ) an Individual Sewage Disposal t s.._ystems _ . .... �� ..... ( t No.-- - --- Y .........--- .... Ow ddress �.., .. - ---------- � Installer Address Type of Building Size Lot..e 2� ......Sq. feet Dwelling—No. of Bedrooms............................................Expansion At is ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons........... -------------- Showers — Cafeteria dOther fix urea------------------------------------------------------------------------------------------------------------------•------------------•--.....------•• W Design Flow......._.... .....................gallons per person err/cay. Total da'l f ow...... a 0...................gallons. WSeptic Tank—Liquid capacity/4gallons Length_Y_7_.......Width._ ........ Diameter................ Depth................ Disposal Trench—No..................... Widt ... ...... ....... Total Length..........r.......... Total leaching area...,-,Z1./....sq. ft. Seepage Pit No....____ Diameter... Depth below inlet--- . ....... Total leaching ar .s . ft. /--------- -------- Z Other Distribution box ( /) Dosing to ) /%! �� Percolation Test Results Performed by I� � ---- Date Gil :.. _minutes per inch Depth of Test Pit.................... Depth to ground water.Test Pit No. 1__ p p p ... fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._ .. 9 •---•-----------------------------••----.......-•--------------...........------•---•-•-•----•---.......................................................•.... 0 Description of Soil......... ......... -------------•---------------------------•-•----------------•------ U - -----------------------------•--•----------------------------•----------------------------------------------. UW --•----------------------------------------------------------------------------------------------------------•---------------------------------....................................................... 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 iITL 1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sued by bo d of health. igne ---- -- ------------------------------------------ .......................... Date A lication Approved B - - ��..... PP PP Y r� - Date Application Disapproved for the following reasons: ----•------ ----- _ -•---------------------------•---•----....---•-------------...--••----------------........-•-------...---I--------------------------•-------------------------------------------------------------------- Permit No........................:-- .. Issued_.....,"( J? ._ Date .. ... - -�-----• - •----Date ....._..-•------------------- No.7 7....![.. ..... y FES......3....,......... � THE COMMONWEALTH OF MASSACHUSETTS' BOARD OF HEALTH 's'cr't........ OF....1 ii-,s�Lk - ,� <.. Appliration for Uiipnsa1 Works Totuitrn.rtiun Permit Application is hereby made for a Permit to Construct (}() or Repair ( ) an Individual Sewage Disposal System at: 1-d / ...... ...........'•---........................................................................ ........__- ______.__..........___....._______._.....-___--............................: Location Addres$, orALot No. / Owner /� 7lAdd .. r fi fly I. !f • __....•-•---------------•----•-•-............---- f Installer Address UType of Building Size Lot_40,.6a_.__._Sq. feet Dwelling—No. of Bedrooms______________________._ __.._Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building _______________ No. of ersons._.______. ! ..._____._.. Showers — � YP g ------------- P ( ) Cafeteria ( . ) Otherfixtures..........................................--------------------------------------------•----•----------------•-----•----------._....-----_...w._..... w Design Flow.....................1.....................gallons per person per day. Total daily flow__________ 7_ >.. _..................gallons. P 9 P y - = gallons ., W Septic Tank—Liquid ca aclt _.�! ]lons Len h_r!'___: __ Width__.`._:__.__._ Diameter................ Depth--------,___,_ x Disposal Trench—No_ ____________________ Width____ .............. Total Length.................... Total leaching area___ 240. ...sq. ft. Seepage Pit No._____._ Diameter_._b ....... Depth below inlet___. '_%... Total leaching ar ._ .s . ft. Z Other Distribution box Dosing tanks ( ) , '-' Percolation Test Results Performed by �!:, /je7 .---- Date _ /a ...-•-- a Test Pit No. 1.__ *_minutes per inch" Depth of Test Pit____________________ Depth to ground water.. '___ !' 1�E Li, Test Pit No. 2................minutes per inel w,;�Depth of Test Pit.................... Depth to ground water_-je- _.1Kc!44 Description of Soil------ r,• x c .- ..__..._._ I --=fin ------•--•- -------•------------------------------------------------------•-•--- . w __ x airs ------------------------------------------------------------------•----------...--------------------------••---------------........ Nature of Re or Alterations—An U P Answer when applicable................................................................................................ ------------------------------------•--•---•---------------------------------------.....----:_......-----....-----------•-----------------------•-------------•-•--=-•-----•---------._..:............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-issued by the board of health. Ine ----------------------------------•---_..__ ..._•------- Applica.tion Approved By-------------f=" ..........._. " 1 .Date 1f Date Application Disapproved for the following reasons: ------------------ ---- ----_-•••---------------•------------------•--------•-------------------------------------------------------------------------------- Date _ PermitNo................................................... -. Issued........................................................ Date T„HFF COMMONWEALTH OF MASSACHUSETTS BOAF4D OF HEALTH .. .�!` !:..`-<.. ............:....OF....�: �`�: !........ •# ,a. Trrtgf tratr of Tomptianrr THIS IS TO CERTIFY; That the In widual SN ge Dls�posal System constructed ,( or Repaired ( ) by ?r _7` / /" /�"G't'#fir; - e�`c° � +.r ......-----••------ `�-----------. --.-•-'--• ---'---- ------ -=------------------------------ �i r.� l- Installer has been i stalled in accordance with the provisions of T Y5 f,The State Sanitary Code as described in the T - -f---2 application for Disposal Works Construction Permit �o... _ _____.__ 4 dated------ .•,__________. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE --`------• ell------------•••••-•------•------------- Inspector..... . . THE COMMONWEALTH OF MASSACHUSETTS f BOARD—OF HEALTH M � *�.t.,. G G��"�4✓...........OF..... 5G `1'/l ! ............................. No......................... FEE:....,. ......... 11ttoposaLIVorkii Tnnsirur#ion Permit 4 Permission is hereby granted....... _ _ .:I!<< `-y' ------------- -------------- +� r----------------------------..........�.................... to Construct (� or Repair ( ). an Individual Sewage Disposal System �. at No-------------- �• !�/ C.e! . -=�- ---p Street as shown on the application for Disposal Works Construction Permit _______ jDate ""'«:".j .............. J �,f Board of Health DATE..............-<•`-'--••--(---e.-------...----- /----................. FORM 1255 HOBBS &,,WARREN, INC., PUBLISHERS t ' ,' r _L�-�:��r.�' c�XS ! i- ��,y,s N v`e,o�F•� �- F"��v t5'h G1[r��E �'►�ve3w G�P�v pE - _.__--_---. . Toff 0 f re v A,0. 1 �rl ' _4'C �' rr-y am _ �-- T - , N�GY a"v�ct �s+rn�Es4.r 4 3�^0Awxi e SL C,O"AW F-j. o®O ftr� • �$YS i ' ;'+ D 115 T 3 O X j j I Gr« rle, to ' -- ---r'a ae Lli vn'. �. 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