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Home My WebLink About0029 OLD KINGS ROAD - Health 29 Old Kings Road ~� Cotuit _ C �A = 022 068 r i i sj Commonwealth of Massachusetts IN' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Old King Road c Property Address N Mark Herder ,. Owner Owners Name information is ✓ , required for every Cotuit Ma. 02635 10/24/2016 page. City/Town State Zip Code Date of Inspection t 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. Impg out When fillip out forms A. General Information on the computer, / use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector Y Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address a� Mashpee Ma. 02649 City/Town - State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification - I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and,complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/24/2016 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 • , Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Old King Road l — Property Address Mark Herder Owner' information is Owner's Name required for every Cotuit Ma. 02635 10/24/2016 page. Cltyrrown State Zip Code Date of Inspection B. Certification (coot.) Inspection Summary: Check A,B,C,D or E/ complete always p to 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: This home has a H-10 1000 gallon septic tank and a H-10 D-Box with a precast leaching pit.At the time of the inspection there was apex 3 feet of ponding water in the leaching 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 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 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 r 29 Old King Road Property Address Mark Herder Owner Owner's Name information is required for every Cotuit Ma. 02635 10/24/2016 page. Cityrrown 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 ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Old King Road Property Address Mark Herder Owner Owner's Name information is required for every COtUIt Ma. 02635 10/24/2016 page. Cityrrown State Zip Code Date of Inspection. B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins•3/13 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 29 Old King Road Property Address Mark Herder Owner Owners Name information is required for every Cotult Ma. 02635 10/24/2016 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. ❑ ® 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 fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts MI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Old King Road Property Address Mark Herder Owner Owner's Name information is required for every COtUIt Ma. 02635 10/24/2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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 CM 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Old King Road Property Address Mark Herder Owner Owner's Name information is required for every Cotuit Ma. 02635 10/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq:ft., etc.): Grease trap present? ❑ Yes .❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 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 29 Old King Road Property Address Mark Herder Owner Owner's Name information is COtUIt required for every Ma. 02635 10/24/2016 page. Cltyrrown 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: Bousfield Septic Pumping 508-888-2010 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1000 gallons gallons How was quantity Drivers Est. q y pumped determined? Reason for pumping: Home owners request 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Old King Road Property Address Mark Herder Owner Owner's Name information is required for every COtUIt Ma. 02635 10/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2911feet 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.): Septic Tank(locate on site plan): Depth below grade: 19"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: standard H-101000 gallon Sludge depth: 3" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Old King Road Property Address Mark Herder Owner Owner's Name information is required for every COtUIt Ma. 02635 10/24/2016 page. City/Town 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 apx. 35" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? 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.):. I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept has a list of local pumping co Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑.concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other :ex lain ( P ) Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle - 1 Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 29 Old King Road Property Address Mark Herder Owner Owner's Name information is COtUIt required for every Ma. 02635 10/24/2016 page. Cityrrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 : Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 29 Old King Road Property Address Mark Herder Owner Owner's Name information is COtUit required for every Ma. 02635 10/24/2016 page. Cltyrrown 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.): At the time of the inspection there no signs of solids carryover or evidence of hydraulic failure 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•3/13 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 Y 29 Old King Road Property Address Mark Herder Owner Owner's Name information is COtUIt required for every Ma. 02635 10/24/2016 page. Clty1rown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ Teaching 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.): At the time of the inspection there was appx 3 feet of ponding water. 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments t 29 Old King Road Property Address Mark Herder Owner Owner's Name information is required for every COtUit Ma. 02635 10/24/2016 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.): 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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsu rface Sewage Dis posal sposal System Form Not for Voluntary Assessments 29 Old King Road Property Address Mark Herder Owner Owner's Name information is required for every Cotuit Ma. 02635 10/24/2016 page. 6VI T own 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 16 .2 9 P .. 301 lvy t5ins•3H 3 Tide 5 Official Inspection Form: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 29 Old King Road Property Address Mark Herder Owner Owner's Name information is Cotuit required for every Ma. 02635 10/24/2016 page. Cltyrrown 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: 15 plus feet 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 ground water elevation: 1 augered a hole at a lower elevation and shot it with a transit to show 5 plus feet of seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form lug Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Old King Road Property Address Mark Herder Owner Owner's Name information is COtult required for every Ma. 02635 10/24/2016 page. Cltylrown 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 � n s s ► 5 �'��5 reel' V I J NO . 14z-0 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth:of Massachusetts . _ Title 5 Official In paction Form m Subsurface Sewage Disposal System Form: Not for Voluntary Assessments `M ,• 29 Old Kings Road Property Address:. Sidney McPherson Owner Owners Name information is required for every Cotult page. City/Town::. MA 02635 .. . . 5/1/14 State ZipCode,:, 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 i4 General Information- on the computer, use only the tab .. I key to move your 1. Inspector: g57q�. cursor-do not use the return . Ricky L. Wright, key. Name of Inspector B&B Excavation, Inc: rab Company Name -14 Teaberry Lane Company Address ' Forestdale MA . City/Town 0 4 State Zip Code (508)477-0653 SI-14595 Telephone Number License Number a B. Certification k certify that I have personally inspected the sewage disposal system at this address and thatthe information reported below Is true, accurate and complete as of the time of the ins.'Pection: The inspection was performed based on my training and experience.in the proper function and malntenance�of o►a�site sewage disposal systems.. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15000). The system: • ® Passes. ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority nspector's Signatur 5/2/14 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 the same or different conditions:of use. perform m the future under t5ins 3/13 Title 5 Official InspVonForm.Subsurface Sewage Disposal System:•.Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 29 Old Kings Road Property Address Sidney McPherson Owner information is Owner's Name � required for every Cotuit MA 02635 5/1/14 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits 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 FIND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 29 Old Kings Road Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 page. City/Town 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 ❑ 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 l5ins-3/13 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 29 Old Kings Road Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 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 supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No -❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins•3/13 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 29 Old Kings Road Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 page. CitylTown 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: ❑ 0 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. I ❑ ® 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 fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Form a Sub surface Sewage Disposal System Form:- Not for voluntary Assessments 29 Old Kings Road Property Address . Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 page. City/Town - State Zip Code Date of Inspection C. Checklist .. .:Check if:the following have been done..You must indicate":yes" or"no":as to each of the following: Yes No ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were:any of the.system components pumped out in the previous two weeks? El 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? El Were:as built.plans of thesystem:obtained and examined?(If they::were not ® available note as N/A): ® ❑ Was the facility or dwelling inspected for.signs of sewage back up? 1Z El Was the site inspected for signs of breakout? ® '❑ 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 El ® information on the proper maintenance.of subsurface sewage disposaI systems?.. The size and location of the Soil Absorption System.(SAS) on.the site has been determined based on: ® El Existing information. For example, a plan at the Board of Health.: Z El 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: 3 ::;Number of bedrooms (design): Number.of bedrooms (actual.): 3 . DESIGN flow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): . 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:-Page 6 of 17 Commonwealth of Massachusetts MM Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Old Kings Road 'M Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 page. Cityrrown 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?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 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? ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Kings Road Property Address Sidney McPherson Owner Owner's Name information is required for every Cotuit MA 02635 5/1/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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•3/13 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 °M 29 Old Kings Road Property Address Sidney McPherson Owner information is Owner s Name required for every Cotuit MA 02635 5/1/14 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: t 1984 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): Distance from private water supply well or suction line: >20 feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in working condition No sign of leakage Septic Tank(locate on site plan): 1 Depth below grade: 2' feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene El 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: 1000 gallon Sludge depth: no sludge t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 29 Old Kings Road Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 page. City/Town 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum 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. No sign of leakage. 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 t5ins•3/13 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 29 Old Kings Road M Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 page. City/Town State Da of Inspect ion D. System Information (cont.) Zip Code te Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I i Tight or Holding Tank(tank must be pumped at time p of inspection) p tlon)(locate on site plan): � Depth below grade: Material of construction: ❑ concrete ❑ metal . El fiberglass El polyethylene El 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 29 Old Kings Road Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 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 5 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 structurally sound. No sign of solid carryover or leakage 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Kings Road Property Address Sidney McPherson Owner Owner's Name information is required for every Cotuit MA 02635 5/1/14 page. City/Town 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.): At time of inspection leaching appears to be in working order. No signs of 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 - I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Kings Road Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 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.): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Kings Road Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I'I A3 JA A3=3d r33 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts H u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 29 Old Kings Road Property Address Sidney McPherson Owner Owners Name information is required for every Cotuit MA 02635 5/1/14 page. City/Town 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 groundwater elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2/6/84 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan obtained from Barnstable Board of Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 29 Old Kings Road Property Address Sidney McPherson Owner Owner's Name information is required for every Cotuit MA 02635 5/1/14 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 j� r LOTION SEWAGE PERMIT NO. �4 � ICJ VILLAGE INST.A LLER S ,L� NAME ADDR S I B U I L D E R 0R OWNER DATE PERMIT ISSUED =J 7 DATE COMPLIANCE ISSUED - � ��8 r �J u�i,�� .�.._.n.------.---�` � � f� �� ' � 1 ��,i 0 s � i'l �� " NOV-/o/ - s THE COMMONWEALTH OF MASSACHUSETTS EO HEALTH��' [co- ... ..---.........OF. STD .� ow Appliration for Disposal Works Toustrurtiort frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: o - - - - = = - � ----•------...-•--•--•-•....... ............... Loca n-A d ress - or Lot No. ................. °� T------... .E ea... �. S T' `Z �..\ F c-r caner / �1 `Addre s an .._... ^' t.:................................ •-•---.... �V.,..............� t..�.�. ..r Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage GrinderWO.11 Other—T e of Building a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------•-------------••--------•----•••---•---------•-----•--•---•-•----•---- W Design Flow............................................gallons per person per day. Total daily flow----..__..I .' . . ................gallons. WSeptic Tank—Liquid capacity.0. 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 ( ) 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........................ 04 .---•••--•-----•----•--••--•----•••-••••------•---••--••-•---•....••---•.....------•--•-•----------------•......-----•-•••-•. ............................... ODescription of Soil.................-----------------------------------------------------•----•-------•---------------------------------•-•---------------------------------•--•--•-.••--- W U ••••••--•••••-••-•--••-•--•--•-••••--•-.....•-••-•--•••-•-------------------------•-------•••••----•-•••--•------••-•---------•----••----------•••••--••-••-•-----•---•--------•---------•-•-•--•----• W x --------------- ......................................................................................................................•---•••-----•-•------•---•--•••---------••......••-•••------•••-- U Nature of Repairs or Alterations—Answer when ,.._..--0_ �......1l._. _._.. -----------------------------••----•---------------------------------------------------------------------•-••........-----••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIME 5 of the St am ode— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sue bI t e�o'�n of health. igned ......... E_ 2- ---- ----•-••--•-•-•-.••-•-- •-•-••---- t //Application Approved BY --------.... p = = Date Application Disapprove or he following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date r THE COMMONWEALTH OF MASSACHUSETTS _ BOARD-OF HEALTH _ a , ._.._..--. -.. . ....------..OF............. ......................... ApplirFa#iun for Disposal Works Tonutrnrtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ®` t ;� Locafr•n- ress t Lot No.or - -*- W .....`Owner C ►AddrQss`} -- ...........• Installer -•---•--.._.........---^----•-•---- -•_...-.•... pq Address UType of Building Size Lot----------------•---•-------Sq. feet Dwelling—No. of Bedrooms.........................................................................Expansion Attic ( ) Garbage Grinder/(� pa-I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures d -----• ................•... W Design Flow.............................................gallons per person per day. Total daily flow.......... r?.� ................gallons. WSeptic Tank—Liquid capacity!.OPQgallons Length................ Width................ Diameter__.____-•-..____ Depth................ x Disposal Trench—No. .................... Width..................... Total Length.................... Total leaching area.....................sq. ft. 3 Seepage Pit No---------------_-_ Diameter-__._....__.__..... Depth below inlet.................... Total leaching area..................sq. ft. t z Other Distribution box ( ) Dosing tank ( ) 1 1 Percolation Test Results Performed by.......................................................................... Date........................................ Teat Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 P4 .-••••••-••--•--------------••••--•--•-•--••••••-•-.._..-•----.....------••-•---•-•--.._..-----•-•--......................................................... Description of Soil........................................................................................................................................................................ V ......_....--•••-•-••-••--•-•------••••---•-••----••---•----•--•-•--------•-•••-••--•-...-------•••••-------•••••-----•-••---•-•--••---••----•--•-••-----••............................................. 0 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 St e anita'ry�.Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ssued b t e c of health. Signed. 4.,.:: _.. - T, 47 --•---......---•-•--- ..... .........-..... Application Approved B�olrh'e .. •-----••-••••-•-----•-••....••--------••-•-------•-------•• --- ' 7= ..Date Application Disapprove following reasons:___________________________________________________________________ ._...___..._. .........-•---•--•----•-•.....-•----•-•---•---•-••----••.....----••-•••-------••--•--•----•--•-•••-•------•-----•-...-••----•-•-----•-----•••--••-----••-••----•--••••••-------•••--•--•---•--•••------- Date PermitNo......................................................... Issued...................................................... THE COMMONWEALTH OF MASSACHUSETTS ------ - BQ/RD--OF-- HEALTH ..........................OF............... .A r�TC.``. .. -.::............ dw we irate of Tunaplittnrr TH,'S.IS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........ ----------..ft....---- ......... ......... ..................-...................................................................................................... at..... .............................!� f/' rdance � . Installer . -• •.---•----•-------•-......-•-•-•-- ---•--------•--------------------•---•----•-• •---•••----...•-•-------•--•••••---••---------•-••...... has been installed in with the provisions of T '' F rr of The State Sanitary C as escyibed in the applicaticn for Dispoorks Construction Permit No• _fG}/� dated_^' _'_ -- __-_ .......................... ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. A. DATE........ ................... -. .----_..... Inspector.......A.....•.dam 9--d- •- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 FEE-J.'.... ............. Diupu n1 Works Tunutr ion Permit Permission . .� f ...-•----------- •---------••---------•---• -----------------------• •-•••--•-..•-•......-•-•••••-••.._ to Consru ) rRpair e ividual Sewage Disposal System Street as shown on the applica=' for Disposal Works Construction Permit No.._...._... /=Datec "...................................... ®® DATE.....................................L�:•L-�-�-��--------•----•-- oard of Health FORM 1258 A. M. SULKIN, INC., BOSTON ... - t . p, E QJF.IDE2 wo Gags G G 330 15a% A956.P. o :+ I us1` %000 GAL. D1SPQ�AL P1T V SE l U 00 GAL. ��✓ S�D4v�lA�L A2GA = �,0 6.F goTTo/A ARF-A - � ; So S.F x 100 o 5' Po' G. �! rcTAI- Dr,-51GN * 42 D. ±: ' ToTA%- DA 1 LY FL.oV,! = 33a G.Po li • � 1 P62CoL.AT1oN RA• G 'V iti VAIN pP,.LESS ' alCF-Ina p 14PAXTER A. } j ��1 �. '✓ i 1 1 To P FWD• AOZ. S ,ccty Ioov INV. �'•-sGVG_ DIST. INV. �A�. f BOX qp SCPT�G L ' iOoo TI; ZLEAG11 ` PIT INV. INV. comic 1'�3/g•t WA c>KG.D faTv N6 } --9zell CE2TIFIGD PLoT Pi-A►W %Z *49.G PRol=ILr= ,00f� Lo4AZ1oN GGtiTuiT' a N o S GALE S CA L M_ : �Q i AT E PL.P►N REPGz G 1 C�cst�FY rTNAT ?HEPP.oP. rWI. :!,"OWN N6R60N GOMPL`(S �11T1.1'LH� SIC�LIN1= ` 47-- 3Q A M 0 swreAG%G R.6QV 2EM6N'T� of 'TNE PG�� Z9 Z -To W N. or- SA i�iS �'> A N'0 115 NoT LOCAT D-WIT141M Tter' 9:%-OOD PLAIN DAl L6 miji 4oc= R c�i�_"'C',.'" gA-P Es t.e m yt- INC. Tal!$ PL&W 15 NET gn-jCzD Old. AN dSTESZVILLE • AM�'SS. DNS-MUMC&NT SUgVe,y 4-THE DhF5E'T5 6ucuL3) woT 5E ,V5EoTO C)E'TEFv^I Lo'r t_1f4E"j APPL1GA►-1.r. ��•' `� _ . . . - � .- Sh/��" z of 2 'i 1.•: QQQ.4''' / - • :�� c/`j/99 L AT a� ou ��'�: '•� 9y z An�� cvP a .. 4 x 5+ F y ti -V/ Z�4477,01J of ti / tiLAN ��' '•w , vi nt C S r. �0. AsBuilt Page 1 of 1 rc/ a/ /f.� -- LOCAT10N SEWAGE PERMIT NO. 4 � � 0J VILLAGE 1N.ST.A LLER'S �( NAME 41t. ADDR S �7rC S U I L 0 E R OR OWNER o DATE PERMIT IS. SUED DATE COMPLIANCE ISSUED nw ��R�� r4 / 1 gP I yn r-d http://issgl2/intranet/propdata/prebuilt.aspx?mappar=022068&seq=1 5/l/2014