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Home My WebLink About0027 NARROWS WAY - Health 27 NARROWS WAY COtuit A = 021 - 112 Commonwealth of Massachusetts RIMMERM. Title 5 official Inspection Form r,.Y Subsurface Sewage Disposal g posal System Form Not for Voluntary.Assessments �,„, rM 27 N v.� arrows Way N 11 Property Address _ 0 Connie Corcoran Owner Owner's Name/ information is Cotuit I/ MA 02832 9-18-17 required for every tn' page. CityfTown State Zip Code Date of Inspection RM Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important:when A. General Information G,+ fillingng outout f forms ✓ �# a / - ```��tt OF uuliiq�i on the computer, ``a�� 4,pe1iv use only the tab 1. Inspector, `s;•' S key to move your Q a; N cursor-do not James D.Sears _.. _ JAMES use the return Name of Inspector _ ru., key. Capewide Enterprises <r•'•.c+ �0:'4 Ili Company Name y'1�•' 'r?tf.4•'G ` 153 Commercial Street INS Biu„aLu11N Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 . S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-19-17 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, 6applicable, and the approving authority. ""This report only describes conditlons 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. i51ne.0oc•rev,6/16 Tide 5Oftal Inspect-on Form:Subsurface Sewage Disposal System•Page 1 of 17 VS 6 a5ed xeJ dH £V£Z L 60Z 02 d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 27 Narrows Way . Property Address Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-18-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® 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: The system is a 1500 Gal. Tank D Box and pit, B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank Is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 yearsfold is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslam•Page 2 of 17 Z a5ed xezI dH £I U L WE OZ daS Commonwealth of Massachusetts Title 5 Official Inspection Form si Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-18-17 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (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 0 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 s stem required pumping more than 4 times a year due to broken or obstructedpipe(s). The Y 4 P P 9 Y 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 K 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 sah marsh t5irwdoc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 £ abed xeJ dH £6:£Z L 60Z OZ daS Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-18-17 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont) 2. System will fall 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 welly". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution ibox above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in i�is less than 6"below invert or available volume is less than '/2 day flow p r l5ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 b a5ed xeJ dH £I•:£Z L i3OZ OZ d@S Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurfaces Sewage Disposal System Form-Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name Information is required for every Cotuit MA 02632 9-18-17 page. Cityfrown 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. ll ® 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.] The system is a cesspool serving a,facility with a design flow of 2000gpd- ❑ ® 10,000gpd, ❑ ® The system falls.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails, The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doo-rev.6116 TO 5 Official lrispw.ion form:Subsurface Sewage Disposal System•Page 5 or 17 5 a6ed xezI dH £V£Z L M OZ d8S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-18-17 per. CityfTown State Zip Code Date of Inspection C. Checklist in h been done. You must indicate" Check if the following have es"or"no" as to each of the following:a Y Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a;plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.W6 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 6 of 17 9 a5ed xed dH U£Z L 60Z OZ daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y( 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-18-17 page. cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 Gal. Tank D Box and pit N umbercurrent of ra nt residents: 0 r Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 2015-276,OOOGal Water meter readings, if available(last 2 years usage(gpd)): 2016-173,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Cornmercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.):. Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5insdoc rev.6116 Title 5 otricial kupeolion Form:SubsuAace Sewage Disposal System Page 7 of 17 L a6ed xed dH b I,U L IOZ OF daS I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-18-17 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained.from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17 9 a6ed xed dH V V£Z L 60Z OZ d@S Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form •Not for Voluntary Assessments F 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-18-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH-40, Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑polyethylene_ ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach.a copy of certificate) ❑ Yes ❑ No Dimensions, 1600 Gal. Precast H-10 4,1 Sludge depth: 15ins.doc rev.6N 6 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 6 abed xed dH V 1,U L 60Z 02 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y' 27 Narrows Way Property Address. Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-16-17 page. City/Town State Zip Code Date of Inspection D. System Information (cone:.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 611 Distance from top of scum to top of outlet tee.or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Asbuilt-Tape- Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and cover's at T below�grade. Inlet tee,outlet baffle. No sign of leakage or over loading. Tank need's to be pumped. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5lns.doc-rev.e/16 Title 5 Ofridal Inspedlon Form Subsurface Sewage Disposal System-Page 10 of V 0l, abed xed dH b 1,U L 60Z OZ d@S Commonwealth of Massachusetts P. R4996999PRtz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name Information is required for every Cotuit MA 02632 9-18-17 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): 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 t5lns.doc-rev.6/16 Title 5 Miicial Inspection Form:Subsurface Sewage Deposal Systam•Page 11 or 17 66 abed xed dH 9LU L60Z 02 d@S Commonwealth of Massachusetts V Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Narrows Way Properly Address Connie Corcoran Owner owner's Name information is required for every Cotuit MA 02632 9-18-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on;site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"06"-22" below grade wlone line out. Box is clean and solid. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 Z i, abed xed dH 9 V£Z L L02 OZ daS Commonwealth of Massachusetts Riwmp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every Cotuit MA 02632 9-18-17 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits' number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit. Pit at 38"below grade w/cover at 10".6"water in pit wl stain line at 1'above water line. No sign of over loading or solid carry over. No high stain line 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.doc•rev.6116 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 £6 abed xed dH 9 6U L 60Z 02 d@S Commonwealth of Massachusetts Title 5 Official Inspection Form �) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every. Cotuit MA 02632 9-18-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc rev.6/16 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 a6ed xed dH 9 6:£2 L l,02 OZ daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owners Name required egr redfo is Cotuit MA 02632 9-18-17 required for every Paw. 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 ❑ drawing attached separately !� EA � I l A y �CK o J l o I '4 8-�t= af - 17" rFNc � A3_ 3 �� 8 -3 = a " /4 - = /3 —y - Al t5ins.Aoc-rev.6A 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 5 a6ed xed dH 96:£Z Ll•02 OZ d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owner's Name information is required for every Cctuit MA 02632 9-18-17 page. Cityt7own state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells a Estimated depth to igh ground water: 13+ 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high groundwater elevation: Hand Auger T.H. 13' no G.W.. Bottom of pit at 9' below grade. Bottom of pit at 4'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins.Coe•rev.SM 5 T tie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 9l, a5ed xed dH 9LU L60Z OZ daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 27 Narrows Way Property Address Connie Corcoran Owner Owners Name information is required for every Cotuit MA 02632 9-18-17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Z. Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6116 Title 5 OffKlal Ins pacdcn Form:Subsurface Sewage Disposal System-Page'17 of 77 L 6 a6ed xed dH 96:£2 L 60Z 0? daS it TOWN OF BA RNSTAB�,L¢E , LOCATION ""'$ WAGE # VILLAGE 671117- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /j/�smf/4 %r (size) GG(J NO. OF BEDROOMS J PRIVATE WELL OR PUBLIC WATER � BUILDER OR OWNER L 2 4l&7' 2�7- DATE PERMIT ISSUED: -m jq� I ?J• q2 -- DATE COMPLIANCE ISSUED: �i VARIANCE GRANTED: Yes No --R Tt No..,��..�. THE COMMONWEALTH Fri AL u I-� TS BOARD ----------------- -- --- ...............OF........... ..... -- ------ .---.. .... . Appliration for Dispuiial Works nstrur Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Of I .. ........ •• Location-Addy or.Lot Np. - n caner �t" dres a ,. -- ,1...__...-•...............^_---......-- G �'l S r.. == '7Y--- .._...... .........-- Installer Address Q Type of Building Size Lot_/...........:.......Sq. feet U Dwelling—No. of Bedrooms_________ _________________________________Expansion Attic (I" ) 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. 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........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ••••-•--•--•---•-•--•------•••-•••-------•-•-•••-------•----•--...--•••----••---•---......--•-•----•......................................................... 0 Description of Soil........................................................................................................................................................................ x W --•-----------------------------•-----•-•---•--•-•------------••-•--••---•---•---------••--•--------------------------------------=---------•----------------------•------------------------------••-•-- VNature 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 TIT11 5 of the State Sanitary Code—Th undersigne further agrees not to place the system in operation until a Certificate of Compliance has bee ed b health. Signed: • -• .....•-_---- •- ........... . ...................... _..•------ -.._........--_... D e q Application Approved By.. `Q••----•••-• •• `.... .... .. .:. °-1 ' �- Sr^ = K��C Date Application Disapproved,for the following reasons-------------------------------------•---------------•-----------•--------------...---...•--•-•--•-•-•••-----••- ----•-.......-••••----•------•-•-•-••-••-•--•------•------•--•----••---•-•••--•••--•••••-•••-•-•••----••-I•-•--••----•---•----•--...•••---•--------------------•-•----•---•----•---•-•------••--------- Date Permit No----j.. " ......................... Issued___ ......... ...� Date ...................... ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .OF...... .� ................. . ................. ,'..<.... . ......... .. .. .... Appliratio t fear Dispos al .arks �at��ra�r�uaat� rrmtt 3 92 a Application is hereby made for a Permit to Construct (P or Repair ( ) an Individual Sewage Disposal System at '� r" r . fi E° r¢ 5 is.... 9a .......... $ r €� 1 rI Location Address , a' or Lot No' } `, t ---- ---------- ter' ..a` g c'ca4 a .•.J. m,i W �yOwner ' �4A�Idresse Installer Address Q Type of Building Size Lot... ....Sq. feet U Dwelling—No. of Bedrooms_ ............................Expansion Attic ( ) Garbage Grinder ( -)�` aOther—Type of.Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 0.' 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.............-----------------•...----- 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.----------------... Depth to ground water'....................... --•....................•------•-•--------------•----•--------------.............._------------•--•--......................................................... 0 Description of Soil...........................•-----•---...-------•------------.........---•------••---•------•-•----------•----........---------•--...........................-------•---- x V -•-•--•-------•---•---------•----------------•.....----•-•-•---•---•-------------........•-----------------------------••--•---••--•----•----•-......-----•--•-•••....--•-•-•--...---•••......------•--- W •----•-•-•-•------------------•----•••-••-----•--------•••-•--------•---•---•---•-•------•-----••----•------.•-•-•-•••-••--•---.._..------•---•---------------------...-•--•-•.._......-•-------------- VNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------•----••-•------•------•--•------------------------...............-•----......------------------------------------------------------------•-•----------__........•----. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The,undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ss ued by`theiboaid-of health �' -n. `�w�� _ '+ 4 Signed R x:� , . .- �- step ,- Application Approved By----- ----- ----- - -- --- ..... .:..q...r:.... .:- ------�------.�--•------•-_�Z �NGr��I�� Date_. Application Disapproved for the following reasons______________________________________________________________________________________________•----•---......... ..-•--------------------------------------------•---•--......----.-......---------••----------•--------..............----•----------------------------------------------------------------•--............. Permit No.....,f�.•'..... . ... .....--J---------------------•-. Issued....31...'_� ._.. Date.. au .... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF...........L.......:............... .................... ...:.................. (9rdifirate of TomptiFattre THIS I O C RTIFY, That the Individual Sewage Disposal System constructed ( �or Repaired ( ) by .. .... ..................•-• ••-•-••--------------•------...... ...•--•--------••----•-----..._....._......------••-- Installer �---a ��T/�J •. has been installed in accordance with the provisions of TITII 5 of The State Sanitary Code as described in the application for.Disposal Works Construction Permit No------- �__,�_�.�_...... dated_..___ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................•.........---------............_..-------•...-•---.---- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �j ......OF..... ...... ............ No.---1 �i FEE.. v ...... wisposFal Works Tuxtrttrti.an amit Permission is reby granted l"1 ... t----__- ----•---•----------- .......... ` to Construct (_ r Repaid ) an Individual Sewage Disposal System ... ..... Stree OO as shown on the application for Disposal Works Construction Perm• 1--��- J• ated-------�- `.....�f-_:��.•-� ......... --- - .. .------.------� / Board of Health DATE.......... I FORM 1255 HOBBS 4ZIRRIEN. INC., PUBLISHERS ■e® Moms OM NI M11111111 ■e�p�p■■CG.� ® ..f�®.....f� f� fa��1�A�lw��r�rY:lrWwWW �A eoon! iii�� i1 ii� V a ®®■■■■■■ ■■■ ■®®®� ■see®®�e■■■■■■■■■■.a■■■■■�� ■■- a��■ wit �' e.. 'wow some® ■■®®e■®■■��11®.tea■■■iC"J■■■■■■■■■■ ■■■■■■A■■ ■ n■ Non a HER muumuu .,i ��e/�l� �. ■■■■mramrIMAUR ■Emmoe■®9�®■ 0.�.��7■�®■ ■■ ��e■ONE■■■ n■ NisiaE® :■e■E■■®■■■®®®o■■■e■■■® !l a■n�0No ■ ■n:♦■■■■■ ■�■,► . . - n■■■■e®■■®■■�■euun■� pq■■r�u7■a�u ■mom� Non® i®■■0 NOism■�■■ �%fM■��7'r;�/4 /!i■■■■■S■■■■■ Nti■ - ,. .. 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