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HomeMy WebLinkAbout0121 OXFORD DRIVE - Health �121 Oxford Drive (cotuit) �A702f:0590L ST. ( f� j t i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Na e -+,7 information is Cotuit ✓ MA 02635 2-28-17 required for every page. City/Town State Zip Code Date of Inspection w Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use key to onlInoue your the tab 1. Inspector: ��P SH of�ASs4�ti cursor-do not John L. Churchill Jr., PE, PLS use the return Name of Inspector 0 CMMCHILLA n key. JC Engineering, Inc. raa Company Name 2854 Cranberry Highway M- O Company Address East Wareham MA V"2538 City/Town State Zip Code 508-273-0377 Massachusetts PE#41807 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 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails. ❑ Needs Further Evaluation by the Local Approving Authority 3-1-17 Inspec 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. I ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doe-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �o VS Commonwealth of Massachusetts - . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is Cotuit MA 02635 2-28-17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or-E/always complete all of Section D A) System Passes: t"�.A�4,�,P ®� I hauexh�ot fofii d any information which indicates that any of the failure criteria described .F: a, in 310 CMR°-15 303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are - Sibel w: , C mments""� � 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts M r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA 4"M y0 , A Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 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): m ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. Cityfrown 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 '/2 day flow l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 . Commonwealth of Massachusetts a Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. City/Town 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. EJ- ® 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. l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. Cityfrown 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 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 gpd t5ins.doc-rev.6/16 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 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: System consists of a 1,000 gallon septic tank, distribution box, and a 1,000 gallon leaching pit. . 0 Number of current residents: 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)): 2016-5 gpd 2015-304 gpd Detail: Sump pump? ❑ Yes ER No June 2016 Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form- Not for Voluntary Assessments - wM 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every COtult MA 02635 2-28-17 page. Cityfrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 121 Oxford Drive, Cotuit; MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 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: System components approx. 19 years old per Barnstable Board of Health as-built card Were sewage odors detected when arriving at the site?- ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.4 feet I 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: 1.7 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: 10.6'x 5.8' Sludge depth: 511 t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured infield Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank is in good condition; recommend pumping tank immediately; no evidence of leakage found. No risers on tank covers. Outlet side has concrete baffle. 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.doc•rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts F g Title 5 Official Inspection Form, Subsurface Sewage Disposal•System Form - Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso, Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. Citylrown 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.doc-rev.6/16 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 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. Cityrrown 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.): Distribution box appears to be level and distribution to outlets appear to be equal. No evidence of solids carryover. No evidence of of leakage into or out of box. Distribution box has riser. Top of riser is approx. 4" below existing grade. 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 Commonwealth of Massachusetts m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1; 6' Diameter ❑ 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.): Soil is in good condition; no signs of ponding or hydraulic failure. Leaching pit was found dry with stain line along inside of pit approx. 8"from bottom of pit. Top pit was found 2.2' below existing grade- No riser. 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 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 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.): l5ins.doc-rev.6/16 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts 4 Title 5 Official InspectionFora Subsurface Sewage Disposal System 'Form - Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA M v• Property Address Mark Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:t 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 3 u 3j S5 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts 3 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is required for every Cotuit MA 02635 2-28-17 page. Cityrrown 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: >12.0 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: 6-17-85 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: Depth to groundwater greater than 12.0 feet established based on test pit data from a Certified Plot Plan prepared by Baxter& Nye, INC. dated 6-17-85. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 121 Oxford Drive, Cotuit, MA Property Address Mark W. &Thomas E. Giarrusso Owner Owner's Name information is Cotuit MA 02635 2-28-17 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �4pYiration for Misposar 6pstem Construction Permit Application for a Permit to Construct( ) Repair()( Upgrade( ) Abandon( ) ❑Complete System [,Individual Components Location Address or Lot No. I a[ Ogdikb bk%vo Owner's Name,Address,and Tel.No. <cjt'uIT- W E'D., .TA&cE$ Assessor's Map/Parcel 0 oL Q 59 L°C)LLC—QG Pvt> 5'T•70-44e5 M*b Installer's Name,Address,and Tel.No.502 c 77-8877 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) oX Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He Signed Date I ("f r f Application Approved by Date Application Disapproved by Date for the following reasons Permit No. nco f 3 Date Issued �o IS s 3 �� No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: J PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes f 2pplicatlon .for -MIsposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ()�t d�'�O MWO Owner's Name,Address,and Tel.No. p Oai x05 CVTVIT W(o 1 e_0LL6%G Pb 7._&�tES Mb Assessor's Ma /Parcel $ Installer's Name,Address,and Tel.No..502 19$77 Designer's Name,Address,and Tel.No. aAkEWIDG 6V'eQr4aj5er5 LU,' Type of Building: ~ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health, N Signed Date ©-� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ad j J Date Issued to — rS— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS b Certificate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(. ) Repaired(x) Upgraded( ) Abandoned( )by e P E�I�E �N `�i , Sg LLC, at DFZt VE e CSZ"T.a/T' has been constructed in accordance ' r with the provisions of Title 5 and the for Disposal System Construction Permit No., bl S-35b dated Installer t:Gm t-DEc Q) L(AC.Designer 01 #bedrooms Approved desig flow A gpd ' The issuance�of this ermit shall not be construed as a guarantee that the system will function designI A_ � 2� -— - _ Date V _ _ _ _ _ Inspector- w.. -----------------------"------------------------------------------------------------------------------------------------------,---------------- No. p261 / 1 3 /G Fee l v v ,. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS: 30isposal 6pstem Construction Permit Permission is hereby granted to Construct( ) ; Repair( Upgrade( ) Abandon( ) System located at O_ 76ILD D&I L/C-- C aT U t-r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. c Date (j^ �S — Approved by i! .; TOWN OF BARNSTABLE `i LJ 1'.TIONZ, ®�C�® �.- t. SEWAGE # VILLAGE `��J`� ASSESSOR'S MAP & LOT-OZJ 0,531 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �r)� CFO-) LEACH124G FACILITY: (type) _Q (size) 00 NO.OF BEDROOMS BUILDER OR OWNER Ga d -PDATE; COMPLIANCE DATE: Separation Distance Between the: . Maximum Adjusted Groundwater Tab Feet .1 Private Water Supply Well and Leaching Facility (If any wells exist �( Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) . Feet Furnished by UD a .0 0 IP W l 9 + � B W N t zt 16 2015 12:48 Jim The Inspector Man 5085349919 page 1 . i I Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Drive , Property Address �•r Warner James ;4 Owner Owner's Name - .c.. information is Cotuit MA 02635 10-16-15 required For every r--v page. Cityrrown State. Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the and of the form. Important:When filling out forms A. General Information j `t���tntwl►Nipi, on the computer, 112,2 `\\����``��tN OFMq 'pig/,G use only the tab 1. Inspector: s� '' key to move your • •'•�ti'� cursor-do not f JAMES =,Grv„S use the return James D.Sears _ ke Name of Inspector y Capewide Enterprises, LLC A 0 Company Name ��, t� RTIF ,. %�O 153 Commercial Street '%qF�s INSpiG��`���` Company Address I Mashpee MA . 02649 City/Town State Zip Code 508477-8877 51623 Telephone Number Incense 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 CMIR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-16-15 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 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•3113 " Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Oct 16 2015 12:48 Jim The Inspector Man 5085349919 page 2 i Commonwealth of Massachusetts _ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive Property Address Warner James i Owner Owner's Name information is required for every Cotuit MA 02635 10-16-15 page. City/Town State Zip Code Date of Inspection B. Certification (coot.) a a j 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: The system is a 1500 Gal. Tank D Box and pit Note: House unoccupied at time of inspection 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 ❑ NO (Explain below): 15ins-3/13 Title 5 Official Inspaction Forth:Subsurface Sewage Disposal System•Page 2 of 17 Oct 16 2015 12:48 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 121 Oxford Drive Property Address Warner James Owner Owner's Name information is required for every Cotuit MA 02635 10-16-15 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 (cant.): ❑ 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem-Page 3 of 17 Oct 16 2015 12:48 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive Property Address Warner James Owner Owner's Name information is required for every Cotuit MA 02635 10-16-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) 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 avempW is less than 6" below invert or available volume is less than '/day flow Pi7-- 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Oct 16 2015 12;48 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Fo rm rrn , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `f 121 Oxford Drive Property Address Warner James Owner Owners Name information is required for every Cotuit MA 02635 10-16-15 page. City/Town 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 r system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins 3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 fOct 16 2015 12:48 Jim The Inspector Man 5085349919 page 6 i i Commonwealth of Massachusetts Title 5 Official ln section Form - p i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 1 121 Oxford Drive Property Address Warner James Owner Owner's Name j information is Cotuit MA 02635 10-16-15 required for every page. CitylTown 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 pan`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) 1310 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 Mns•3113 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Pape 6 of 17 l Oct 16 2015 12:48 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurrace Sewage Disposal System Form -Not for Voluntary Ass 1 ° Y ry Assessments 1 8` 121 Oxford Drive Property Address i Warner James 1 Owner Owner's Name information is Cotuit MA 02636 10-16-15 required for every page. Citylrown State Zip Code Date oflnspection D. System Information Description: The system is a 1500 Gal. Tank D Box and pit Number of current residents: 0 Does residence have a garbage grinder? El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013-73,000Gals g ( y g (gP )�' 2014-142,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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: 15iris•3/1J Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 Oct 16 2015 12:48 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l 121 Oxford Drive Property Address Warner James Owner Owners Name information is required for every Cotuit MA 02635 10-16-15 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Dace Other(describe below). General Information Pumping Records: Source of information: 02 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page It of 17 Oct 16 2015 12:48 Jim The Inspector Man 5085349919 page 9 �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive Property Address Warner James Owner Owner's Name information is required for every Cotuit MA 02635 10-16-115 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: 1985 Permit 85-680 New D Box 10-2015. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 30" 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): Depth below grade: 20„feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) ` If tank is metal, list age: years I Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No • Dimensions: 1500 Gal. Precast H10. Sludge depth: 2" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 9 of 17 Oct 16 2015 12:48 Jim The Inspector Man 5085349919 page 10 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments j - i 121 Oxford Drive Property Address 1 Warner James Owner Owner's Name information is required for every Cotuit MA 02635 10-16-15 page. CitytTown State Zip Code Date of Inspection D. System Information (cont.) 'i Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" 1 i Scum thickness a 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 17" i How were dimensions determined? Abuilt-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 covers at 20" below grade. Inlet tee,outlet baffle. No sign of leakage or over loading. 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 Mrs•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 10 of 17 Oct 16 2015 12:49 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 121 Oxford Drive i Property Address Warner James Owner Owner's Name information is Cotuit MA 02635 10-16-15 �I required for every , page. Cityfrown 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.): i i i 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 I 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•3113 Title 5 Official Inspection Form:Subsurface Sewage oispow system•Page 11 of 17 Oct 16 2015 12:49 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 121 Oxford Drive Property Address Warner James Owner Owner's Name information is required for every Cotuit MA 02635 10-16-15 page. Cityrrown 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"x 16"-28"below grade wlone line out. Box is new 10-2015 wlcover at 4" Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Noy 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 I t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal Syslsm•Page 12 of 17 Oct 16 2015 12:49 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive Property Address Warner James Owner Owner's Name - information is required for every Cotuit MA 02635 10-16-15 page. Cityrrown State Zip Code Date of Inspectlon D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions, 1 ❑ overflow cesspool number. i ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of 1 vegetation, etc.): Leaching is a 1000 Gal. Precast pit w/1'stone. Pit and cover at 27" below grade. 20"Water in pit. Last inspection in 2012 water level was at 2' below inlet. i i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration i Depth —top of liquid to inlet invert Depth of solids layer i Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3113 Title 5 Officlal Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 iOct 16 2015 12:49 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive Property Address Warner James Owner Owners Name information is required for every Cotuit MA 02635 10-16-15 page. CitylTown 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: k Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Oct 16 2015 12:49 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 121 Oxford Drive Property Address Warner James Owner Owner's Name information is required for every Cotult MA 02635 10-16-15, page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) 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 REAR A .D CX it -3 , 39 ` o t 3 �.. 10 151ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Oct 16 2015 12:49 Jim The Inspector Man 5085349919 page 16 '' i 1 Commonwealth of Massachusetts R.9E1W;E999=WP Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive j Property Address Warner James Owner Owner's Name information is 1 required for every Cotuit MA 02635 10-16-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Nv Estimated depth to high ground water: 204 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: on file at B.O.H. ❑ Checked with local excavators, installers-(attach documentation) ' ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Per asbuilt and const. permit. 204 to G.W.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 16 of 17 Oct 16 2015 12:49 Jim The Inspector Man 5085349919 page 17 jl 6 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Drive Property Address Warner James , Owner Owner's Name information is Cotuit MA 02635 10-16-15 required for every i page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3013 Title 5 Official Inspec'lon Form:Subsurface Sewage Disposal System•Page 17 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Cityrrown State Zip Code Date of Inspection a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms the computer, r,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector — use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 Citylrown State Zip Code 508-428-1779 SI 12855 _ 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 Evalu tion by the L al Approving Authority @ , March 8, 2012 Job#12-35 w In ector's Signature Date ;.3 • 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'fhe report to the appropriate regional office of the DEP. The original should be sent to the system�owndin- 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 1 1/10 Title 5 Official Inspection Form:Subs A ce wage Disposal System•Page 1 of 17 a f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Cityrrown 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: Tank was not in need of pumping at time of inspection leaching pit had 16-18"of effective leaching. 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•11/10 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 M 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due! to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 or 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every 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 watelr 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•11/10 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 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ 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 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 — 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): — t5ins•11/10 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 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every 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?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A Irrigation g ( y g (gP ))' System. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. 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-11/10 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 °M 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped two years ago. 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): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every 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: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Septic Tank(locate on site plan): 16" _ 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2" — t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Citylrown 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 28 — Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert and tees were intact. 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 — l5ins•11/10 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 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Cityfrown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 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.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Liquid level was found 2' below inlet pipe with a high stain line 4" above current level. Pit has 16-18" of effective leaching. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert — Depth of solids layer — Depth of scum layer Dimensions of cesspool — Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 aft7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Cityfrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts Title,5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Road _ Property Address --- - -- Warner James Owner Owner's Name - ------ ---- --- information is required for Cotuit MA 02635 March 8, 2012 every page. Cityfrown 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 El drawing attached separately / Back 33 Yard 18 40 23 55 31 i;wa Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Cityfrown 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: 2 fe eett 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: pate ❑ 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 10 and topo map shows property at el. 50 Before filing this Inspection Report, please see Report Completeness Checklist on next page.. 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 a`17 r Commonwealth of Massachusetts = Title 5 Official Inspection Form + Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Oxford Road Property Address Warner James Owner Owner's Name information is required for Cotuit MA 02635 March 8, 2012 every page. Citylrown 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 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 -\ COMMONWEALTH OF MASSACHUSETTS pal_D6-9 x w EXECUTIVE.OFFICE OF'ENVIRONMENTAL AI'FAIRS DEPAR.TMENT.OF ENVIRONMENTAL PROTECTION ti a 'V l y ' TITLE 5 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS " SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. RECEIVED 4 Owner's Name. Owner's Addre AUG 2 7 2001 Date of Insp TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector: (please riot) r4 T, p.I` Conipany Name Mailing Address: p Telephone Number: , / CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and cotriplete..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 M5 ..40 of Title 5(310 CMR 15.000). The sys.teni: -/Passes Conditionally Passes ids. urther Evaluation by the Local Approving Authority. ails - 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. Notes and Comments a ****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. Title 5 Inspection Form 6/15/2000 page 1 j; Page 2 of I l OFFICIAL INSPECTION TORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'. . . PART A CERTIFICA-+ION (continued) r Property Address: . Owner: _ Date of pectin : Inspection Siiimmary;.•Clieelc A,II,C D or E/ALWA S complete all of Section D' A. ystem Passes: e not found an. information which.indicates hat an of the failure criteria described in 310 CMR l ltav , y Y 1`'5 303 or in,310"CMR 15.304 exist.Any failure criteria n t evaluated are indicated below:. ' Comments: t .. t i 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 replacemen or repair;as approved'. pproved'by the Board of Health,will pass. .Answer yes,no or not determined(Y,N,ND).in the. or the following statements. If"not determined"please explain. The.septic.tank-is metal and over 20 years old*'or. he septic tank(whether metal or not) is structurally unsound;exhibits substantial infiltration or-exftltration ortank-failure is imminent. System will'pass-inspection'if the existing tank:is replaced with a com plying'septic taik'as'approved by the Board of Health. *A metal septic tank will pass inspection.if it is structuraly sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or higli static water level in the distribution'box due to broken or obstructed.pipe(s)or due to a broken;settled or uneven di-tribution box. System willpass inspection if(with . approval of Board of Health): broken pipe(s)are re laced obstruction is:,remov. d distribution box is,.le.i eled or replaced ND explain: The system.required pumping more than 4 times a year due to broken or,obstructed pipe(s).The system will pass inspection.if(with approval of the.Board of Health):. broken pipe(s)are rep aced obstruction.is remover ND explain: Page 3 of I'1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE.DISPOSAL SYSTEM INSPECTION F.0RM PART A CERTIFICATION(co»tinu..ed). Property Address: f�4 Date of r spect tin: /' 7/0/ C. Further Evaluation is Required by the Board of Health: Conditions,exist which,require further evaluation-by the Board of Health in order to detennine if the systenn is failing to.protect public health, safety or the environment. I. System Nvill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b.).that the system is not fultctiotfing'm a manner whicb,will protect public health,safety and the environment: — Cesspool or privy is.within 50 feet of a,surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is.functioning iu a.manier that protects the.puhlic)teallli,safety aid.eivirontt.ieti.t: _ 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:.systein has a septic tank and SAS and the SAS is within a Zone l 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,feel but 50'feet or more from a private water supply well.**. Method used to determine dis-tapce **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp in,provided that no other failure.criteria are triggered. A,copy of the analysis must be attached to this form. 3. Other: 3. Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASS>CSSM)CNTS SUBSURFACE SEWAGE"DISPOSAL SYSTEM INSPECTION FORM PART A . .'CERTIFICATION(continued) A Property Address: Owne Q. sp4ecti Dateo �J/�►e 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.sew.age into.Wility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluentto 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 I, cesspool �Liquid depth in cesspool is.less than 6"below invert or available volume is less than '/z day flow Required;pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. J 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'l of a public well. Any portion of a cesspool or privy is within 50.feet of a private water supply well. Any portion of cesspool or.privy is Tess 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 coliform bacteria and volatile organic.compounds' indicates that the well is free froth pollution from that facility 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 formal (YesMo)-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 contaathe Board of Tlealth to determine what will be necessary to correctthe failure. E. Large Systems: To be considered a.large;system:thesystem musf serve a facility with a-design:flow of 10;000 gpd to:15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large.systems in addition to the criteria above) yes no the system i.s 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 lI of a public water supply well If you have answered"yes"to any questibn 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. 4 Page 5 of l.I OFFICIAL INSPECTION FORM:—NOT FORNOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`F.ORM PA'It`T 13 - CHEQUIS'I' Pruper.ty Address: / A Owner: Date of pe-Ji� -17 7A/ Check if the following have been done. You must indicate"yes" or"no"as to each of the.following: Yes No I� Pumping.information was provided by the owner,occupant,:or:Board of Health. V—Were.any of the system components pumped out in the previous two weeks? 1" Has the system received normal flows in the previous two week period'? -ZI-Iave 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 foie signs of sewage Backup ? t.-'-_ Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? _L,e� Were the septic tank manholes uncovet:ed,.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 witli.information on the proper maintenance of subsurface sewage disposal.systems 7 The size and location of the Soil Absorption System (SAS)on(lie site.has been deteriiiued based on: tto _ — Existing.information. For example,a plan.at the Board,of Health. Determined in the field(if any of th Cis failure criteria related to Part is at,issue.approximation of distance is %acceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 1 I OTI+IC::IAL-INSPCCTIONYORM-.NOT TOR VOLUNTARYtASSI+SSMPNTS . SUBSURTACT SEWAGE"DISPOSAL;SYSTEM INSPrCTION FORM :PART C SYSTtM"INrOAMATION Property Address: _ Owner: Dateo.f. sped n: FLOW CONDITIONS RESIDENTIAL, Number of bedrooms(design) j�3: Number of bedrooms(actual):. DESIGN flow based on 39 0 CMR 15.203 (fqr example: 11:0 gpd x#of bedrooms): Mimber of current residents: .. . . �•,• -.:,.. .._ is,.' y , Does:residence-laave.a garbage grinder(yes or no):- - Is laundry on a separate se\wage.system(yes or no) [if yes separate inspection required] Laundry system inspected(yes or no)L/' Seasonal use:(yes or no) 4-:. . Water meter readings, if available(last 2.yeses usage.(gpil)); Sump pump(yes or no Last date of occupancy; ✓�� t r�( �.44W COMMERCINUINDUSTRIA."UU Type of establishment Design flow.(based on 310 CMR.15:203): gpd . Basis of design flow(§eats%persons/sgft,etc,): . :. Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):- Water meter readings, if Available: Last date of occupancy/use: OTYIER(describe): GTNERAL TNrOn)VTATION Pumping Records , Source,6f informafion:. Was system pumped as part of the fnspectKn.(yes.or no):If yes, volume pumped gallons;--Tlow was quantity pumped iletermmed? Reason'for.pumping: . T Or SYSTIM yptic Tank,distribution box,s'oil'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') _Tight tank _Attach a copy:of the D.EP;approval (, _Othet'(describe): �,(J`�''D nCn all components,,d�afe Installed(if cno�, n)and source of infor mation: Were:sewage odors•detected when arriving at the site(yes'or no gg_ 6 y ,�0 4x eel I ` i Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR°VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION(continued) Property Address: f 0 A Owner: Date of pectin : 9t:z 7 C3 I BUILDING SEWER(locate.on site plan) �Ld` Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private.water supply well or suction line: Comments(or►condition of joints,venting,evidence of leakage, SEPTIC.TANK: I/(locate on site plan) �i Depth below grade: P-_ _ Material of construction:, weconcre.te_metal fiberglass��olyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):^(attach a copy of certificate) Dimensions: 10,`J` k k l Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 00 Scum thickness: �� 11 Distance from top of scum to top of outlet tee or baffle: _ I/ Distance from bottom of scum to bottom of outlet tee or baffle` How were dimensions determined: tQ(.,(! —Ph�/� 1a2 Comments(on pumping recommends ions, it let and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): j fa c�/11 e it'- "Z;vC ep to I GREASE TRAP• :, Oovate on site plan:).. Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scwn 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: Conunents(on pumping recommendations, uilet and outlet tee or ruffle condition,structural integrity, liquid,levels as related to outlet invert,evidence of leakage,etc.): 7 t Page 8 of I 1 OFFICIAL_INSPECTION FORM.='NOT FOR WOLUNTARYASSESSMENTS SUI SURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM .,PA RT C SYSTEM'INFOW'A"TION''(continued) Property Address: ,c Owner. Date of , sppecti n: TIGHT or HOLDING TANK (Onk 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: 0;`,f present must be opened)(locate on site plan) Depth of liquid level above outlet invert:. Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of . :lei. age into or out f box, et . ip �ie PUMP CHAMB.ER:l.Alocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): s Page 9 of I 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUI1FACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j f SYSTEM INFORMA 1 ION.(continued) Property Address: /1. ,4 Owner: Date of pecti• is � 7�0 SOIL ABSORPTION SYSTEM (SAS):. ocate on site plan,excavation not required) > If SAS not located explain why: Type leaching.pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: ` leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil; condition of vegetation, 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 or no): Comments(note condition of soil,.signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 3 PRIVY (locate on site plain) Materials of construction: Dimensions: Depth of solids: Comments(note condition.of soil, signs of hydraulic failure, level of ponding,condition of vegetation,.etc.): 9 Page 10 of l] 1 . OFFICIAL INSPECTION FORM=1�OT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM"INSPtCTION FORM P RT C SYSTEM INFOIWATION(continued) Property Address: e ` /�Ldz1 Owner: Date 0f.. .specti /7/OJ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includi g ties to at-least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the ?Vildigg. h ,- 6V L//Mx� t� i - I . I10 f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: el5' Owner: Date of 1 eedo �/7/0/ SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water *ZZ'feet Please indicate(check)all methods used to d.eterniine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: jZhecked with local excavators, installers-(attach documentation) Accessed USGS database=explain: You must describe how you established-the high ground water elevation: TOWN OF BARNSTABLE SEWAGE# VILLAGE ��tJ �� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type).— d (size) C NO.OF BEDROOMS s BUILDER OR OWNER DATE: 9 COMPLIANCE DATE: -PEWRFPSeparation Distance Between the: q 10 Y Feet Maximum Adjusted Groundwater Tab Private Water Supply Well and Leaching Facility (If any wells exist fJ Feet. on site or within 200 feet of leaching.facility) Edge of Wetland and Leaching Facility(If any wetlands exist �1` /�� Feet within 300 feet of leaching facility) �� S �' • ' Furnished by. 17 C T ION/ JA SEWAGE PERMIT NO. Alo ��s7Cav�P ,Ov�v� "y 40010� we y VILLAGE —y- - �e� INSTALLER'S NAME A ADDRESS JOHN A. R^i TO BACK HOE SERVICE J a. nut Sii'L ;t West Barnstable, Mass. 02668 .� B U I L D E R OR OWNER / DATE PERMIT ISSUED I� DATE COMPLIANCE ISSUED j'_ 23-5 f a S 31 ' Y T > Fxs... .............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH M..............OF....... ! .t .�� (v ................. Appliration for Disposal Works Tonstrnrtiun "anti# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. llA1• "ka2._.�L:T.'1� :._.. .............. ©_11�1.t�►�_ caoT� 1�4�1 1 ...........�o. s7:¢ Owner Address W .' .. ...........•-----......-----.----------•----------.-_- .....MAL$ 645... ,.`� .......................................... Installer Address U Type of Building Size Lot..Q; 13.0...Sq. feet �-, Dwelling—No. of Bedrooms_._..S...................................Expansion Attic $jt)> Garbage Grinder 0-6 a'4 Other—T e of Building No.,of persons............................ Showers YP g --------•------------------- P ( ) — Cafeteria ( ) Otherfixt es •--•••-••---------•----•-------•-••-------------•••--.--------•---••---- •-•--------•------•-----•••----•-----------•-••-----...........--.._...----• W Design Flow......__...J gallons per person per day. Total daily flow.............. 3:_ `.................gallon . WSeptic Tank—Liquid capacityI allons Length .^�a_...._ Width.f!940.. Diameter-.— Depth_____________ _ x Disposal Trench—No......... ..... Widt ................. Total Length......._.__.. Total leaching area....................sq. ft. Seepage Pit No..__.... - _ Diameter..... _--------- Degill. below inlet...-._....._... Total leaching area...Z®Q.sq. ft. Z Other Distribution box Dosing tankk7 a Percolation Test Results Performed by.......................................................................... Date............ bb.tt... Test Pit No. 1....Z z.---minutes per inch Depth of Test Pit.'Z-............ Depth to ground water..MoT ct a i 44 Test Pit No. 2................minutes per inch Depth of Test Pit...._............... Depth to ground water........................ W .........-----•--• ----- ----------- O Descr'ption of Soil Q..'"2........ �r�z .. So2SQ.��-. Z- L. Acb.�_._: . x !5AC�-p -------------------------------------------------------------------------------------------------------------•-...-•-•---------- w --------------------------------------------------------------------------------------- ...... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --•---•------------------------------------•--•-------------------------•--•-••--------------------_---........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certi P' te f Coryipli ce as been issue Vthedoh h�( S n � ... Date Application Approved By-- --•---..._r !? ._ :. ,oJ - ���z!`�# Date Application Disapproved for the following reasons:............................. . ------ ...................................................... .....................................................................................................-......................-----------------_.... Date Permit No.......� .......�, ©.._........ Issued-...........•........................................... Date _51, r. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ._ cam' J t's...----.....OF........ :'.A,.(LY.s].5..�Tog�3'h.�' Alip iration for Bispaial Works Tonstrnrtian Prrutit Application is hereby made for a Permit to Construct ( `kor Repair ( ) an Individual Sewage Disposal System at �� t . ...c ........... ....tJ/la -A—wl-- t4 v i Q1.._....1?.... I .r TKu.s ---------------------------- �yiy l ?oo�.._ 4r�t ....l c s i ....... Owner A / j�ld J1, •�- - I /�Address a T�........A 1. C!`-/wKJ t O�/s ......:a../L�S. Installer Address U Type of Building Size Lot--- ._®:t..13Q..Sq. f t Dwelling—No. of Bedrooms---_�..................................Expansion Attic (46, Garbage Grinder: p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) aOther fixt .es .....................................................---•--•----•-••---•-••••------... ...-----•---•-••-•------------ d W Design Flow............_..._?.....................gallons per person der day. Total d it flow_........._...�3�50')......--....._ lo4n4. WSeptic Tank—Liquid capacity.:Ll?U�allons Lengths8- ^(6.--.. Width..'_+40 Diameter................ Depth_....__�. x Disposal Trench—:VQ_____________________ Width.................... Total Length............. Total leaching area....................sq. ft. Seepage Pit No.--•-..-_--1:____ _. Diameter...... ........ Depth below inlet............... Total leaching area...Z©_dsq. ft. Z Other Distribution box ( jk Dosing tank (4'tj aPercolation Test Results Performed by......................................................................... Date.....................7-------- Test Pit No. I....4 2...minutes per inch Depth of Test Pit...1 .............. Depth to ground water...KP.T.k1.J_.cbvW eeA?')? f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----- ---------------------------------------O Description of Soil.......�• C'= t c-,,,+n l _ t I ��C.% (— �-� Z :._' ti - IL. 1 1`` --------- x ....------•-- V .........--••••...•---••----_•.............•-••-•••------•-•--••...-•-----•--.,....---..........-•-•-----••-•••.........---••-•------••-•••--•-- --------------...............................................................................................................................................--•-------------------------•-••-------- U Nature of Repairs or Alterations—Answer when applicable____--•-------------------------•-_-------_---•-•------•-------_------------_---•---_--------_. --------------------••------•----•---•---------...------------------------------------........--....••--••--------•-----------•---••---•---•---•••-•---•------------------------•••---•-....._..-•-••--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 f the State Satpitary Code -The undersigned further agrees not to place the system in operation until a Certi s been issu ' -the bo doh th. Si . ••. gip/ "�- ,r^� k Application Approved By--•- te D� Date Application Disapproved for the following reasons-------=-=-----•--------------•--•............................................................................ ---------------------•-----------...---------------•--------••-------....-------••--------------.---•----------------------------------------------------------•---------•------------------------------ Date Permit No..------. " (2)0_0--------• Issued........................................................ Date .—THE-COMMONWEALTH OF MASSACHUSETTS 4 BOARD OF HEALTH ........�o.c.0.4..........OF........&J2 C!S.T 6 ..........................................i` � ; Turdifiratr of Tnntplitanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ---•--------•----•-••--•--••----•------•------•-------•...............•-•••-•••-•-•.....---•-- Installer at... .Q` -- ---------- ..----------•----- ?���' �� �41.0-.----------CD-OTv............................................ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the ti application for Disposal Works Construction Permit No..__... f:_. "_..�_.. dated------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A G RTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ii DATE.............t.1---------------------- ....._...... Inspector........... 7 THE COMMONWEALTH OF MASSACHUSETTS �- BOARD OF HEALTH ......... 1 v� .........OF.........1:>i44a 5..rgA.4.t ................................... No..... €:•', + FEE........................ �i���a��a1 /nrk� �nn��rnr#Uan rrnti� Permission is hereby granted....... /X' ....... 4 11_rO to Construct ( Armor Repair ( ) an Individual Sewage Disposal S stem at No.............4o•......58._.A------..OX�.t,0.--....... 1-.tl.� ...................6, ... Street as shown on the application for Disposal Works Construction Permit No:t_r oqo Dated........ 1. _ ,--_• ...............................� r,. - A DATE....................................... FORM 1255 HOBBS & WARREN.. INC., PUBLISHERS S/N6L:E �F,4iy/L Y �- 3 BE0,2oOM i A,10 GLI,2,8AGE G.e%t/OE.e //Q X 3 = 330 G.P. SE.�T�C T,4.c/!L = 334X/�..o o ='S`9S G.P.O. ,G�T• L O/S.�C2S,4L P/T•-USE /,OG4 6'!-1� . �, '. V� 72 •�ZS G.P �3.30 G..40• . . _o /c% �E'2COL47la,V. JT C 67 RICHARD VAN 6aXTER No. 29733' ti. �t,� f1•, rs o. D , TEST f/a�•E /a/_ 7 FG• _ !v2.0 r, �. ate' A/1/. AVBOX /DU.� /��� �• t�aoa sir�. c 7 S.EPn'G W-/ 'X// �/ TA^�1G ��/an� • • �fi�.�E G'E.2T/F/EO PG OT PL4�✓ -.�/�{--- -�{�•�.._ LoG.�T/arcs �'�-�/ 7— f�L.4.V _., 2E�E.2E:VC� T fir- A,moo (A14 T�2 / G�eri�Y 7f/,4T THE .CCx AAA---1477ol l,S.yo w-lV ..- ,�/E,�Ea.v G"OMP/•Y.S !�d/T/-/TiyE.S/O�'�/�/E B.4XTB.2�NYE /.yC. ,d�vo��T.a/��` .e��Jv�,eE�1�Nrs o� Th�� ,C�EGisr�.ec=O,G4No.Sli,2YEya,Ps m- L aC.arE.o �it�/TH/y T,�,�E �L daOpL4/mot/, T.WaAv,4 AX iiY.sT,2- : -!/tiIEiYT..SU,e!/EYfJit/.� T//E a�FS�TS , .S�l t�N fj�E,e�4N S.�oUG O�aT!�E USEp • CO`t siONN�-EALTH OF MASSACHL SETTS E?�ECL'TIVE OFFICE OF E*NNIRONMENTAL AFFAIRS DEPARTNIE 'NT OF ENNIRONN ENTAL PROTECTION Co p E Vt'1 7ER STREET. BOSTON. NtA 0-1.05 61.:-:5:•fir ,�, • _ TRLMY Co?c S tjpvemc• .••t ..7 .r :r �==— ARGEO PAL1 CELLI'CCI DAN'ID B STRL'F•- Lt,Gavrnoi SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM Commission_. Ale- 0�-iPART A e F�J� CERTIFICATION o f 1 ' ;�rape•tY Address'\2� o>L� �9 C�( Qf3Tv� Address of Owner. 61r\?wS ¢�Q, :of different) ' Date of Inspection: S i5 Name of Inspector. 1`d.r-l. o P eC�o ` 1 { I am a DEEP ap roped system inspector pursuant to Secttan'13.330 of Title 3 p10 CMR 13,0001 P ; Company Name:&/ c ar,7c"e 6 7M N', I'r1 Mailing Address: 2 el l�o� �3�C1 . H RSf,/oPQ /->' 0 2E-�-q • Rruivia Telephone Number. r-Se��CLqt;- . - .. M AY 2.'2 1998 f CERTIFICAT10ti STATEMENT 1 cer;iN that I have pe•scnally rr.spected the sewage d!srasai •ster s\ n a•, this address and tha. the iniorn'at,on resorted be'0 HEALTH DFPf aCCUreie. ar.d cormolete as of the time of rnspec:,o-. The rnspec:;cn was pe^ermer base: act m� training and experience mthe proper tu'Crc' a-e�� maintenance of on-sae sewage disposa; systems. The m;err.: Passe: � ,� '" • " .. . _ Concit,o•:aii% Passe _ ♦eecs Furthe• Eva?uat�c- Ev the Local Ap;rov+ctg Authont) _ _ O ates Inspector's Signatu Loa T:ie Svv.e^ Ins _o• shall submu a copy of this inspeG.an reocn to the Approving Autheriry within thine, (30, days of t:ampleang this system o• has a ce:�gn now of 10.000 gDd or greater, the inspector and the system. owner shall submit inspection. It the system is a sharec the repo- tc the noropnate reg,enal office of the Depa-ment of Envirenmenta* Frotec;ior.. The crigma! should be sent to the s,.;stern c ne- and copes t-•tt to the buyer, if applicable. and the ap-craving authority INSPECTION SUMMARY. Check A, E C, or D Al SYSTEM PASSES: I Brave not found any information which indicates that the system violates any of-the failure criteria as defined in 310 CMR 15.303: +Q, Any failure criteria not evaluated are indicate^ below.' ., COMMENTS: } BI .SYSTEM CONDITIONALLY PASSES: One or more system components a3 described in the 'Conditional Pass' section'need to be replaced or repairer'. The system, ueoi. completion of the replacement or repair, as approved by the Boatel of Health, will pass. Indicate yes• no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of `.Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: c the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or t3nl failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic cnk w approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A : CERTIFICATION (continued) = Property Addcvss: ' . '. . :. --. -. ..: :-. ... ._ _ . . .. .• ; ,' - . Owner: : . . Date of Inspection: B) SYSTEM CONDITIONALLY PASSES tcontinjh i - _ Sewage backup or'breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, sealed or uneven distribution box. The system will pass inspection ff(with approval of the ' Board of Health). Describe observations: broken pipe(s) are replaced - .. _ .e :'. .... •• bstru Rion )s removed O 1` r lad ds w i ribution box is lev e(ed o rep ce t h tern required pumping more than four times a year due to broken or obstructed pipesl.:7he system will pass _ The systern e� P P 8 - insoection if (with approval of the Board of Health): Jr - ' i are replace broken .s p r. removed io is o5struct J . . . C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire furthe•evaluation by the Board of'Health in order to determine if the iystern is failing to protect the public health, saier•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETEiLM zi INE5 THAT THE SYSTEM IS NOT FUNCTIONING Its A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA AND THE ENVIRONMENT: _ Cesspool or pri.ti is within 50 ieet of a surfsy'e water - Cesspoc! or pri%%- is within 50 tee; o: a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF H ALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE") DETERMINES THAT THE SYSTEM 15 FUNCT10ti11G•1N A MANNE THAT PROTECTS THE PUBLIC HEALTH ANO SAFzil!AND THE ENVIRONMENT: The intern has a septic tank and oiI absorption system (SAS, And the S.t is within 100 fee:to a surface water supply tributan to a surface water sup ;. _ The system has a septic tan), d sail absorption systern and the SAS is within a Zone I of a public water supnty we!1. _ The system has a septic tank nd sb'il absorption system and the SAS is within 50 feet of a private water supply well. _ The syste-n has a septic to and soil absorption systern and the SAS is less thar. 100 feet but 50 feet or more from a private water supply well uniess a we!l water analysis for eoliform bacteria and volatile organic compounds indiates tha the weft is free from p ution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Me od used to determine dismnce (approximation not valid). 3) _ OTHER (revisal 04!2s/3') Page 2 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM PART A CERTIFICATION (continued) Property Address: Owner: �.. Date of Inspection: R DJ SYSTEM FAILS: You must indicate either 'Yes" or "tio" as to each of the following: ' d I have determined that the system violates one or more of the following failure criteria as defy ed in 310 CMR 19.303. The basis for this determination is identified below. The Board of Health should be contacted to dete ine what will be necessary to correct the failure. , Yes No _ ' 1 Backup of sewage into facility or system component due to an overloaded or clogged SAS,or cesspool. Discharge or ponding of-effluent to,the.surface of the ground or surface w ten due to an overloaded or clogged SAS or cesspool. Start liquid level in the distrib,,tion boa above outlet.invert due to a overloaded,or clogged 5AS or cesspool. Liauid depth in cesspool is less than 6" below invert or available lume is less than 1/2 day,tlov. _ Required pumping more than, 4 times`in the last year NOT due o clogged or obstructeo,pipe:s Number o'times pumped Any portion o-*the Soa Adsorption System, cesspool or pri is below the high groundwre• eievanor. Any por:on o:a cesspool or prw� is within. 100-feet of surface water supply or tributan o a'surface'v:ater supply. Any por;ion of a cesspoo: or pri%y'is'N rthir, a Zonel f a public well. Am pe^uo- o:a cesspool or pny. is within 50 f of a private'water supph well Am•por,,or. o-a cesspool or privy is less than 00 feet but greater than 50 fee, from a private water supph• well with no accexable water qualu� anah'sis. If the well as been analyzed to be acceptabie.'anach cop. of well water analysis for colrtorm bacteria volatile organic eompoun s, ammonia nitrogen and nitrate nitrogen, E7 LARGE SYSTEM FAILS: - 'You must indicate either "Yes' or ",tio" as to each of the (lowing.. The folioN:ng criteria appi% to large systems , addition to the criteria above: G The system serves a facilit/4a esign fl w of 10,000 gpd'or greater'(Large System; and the system is a significant threat to public health and safer} airon nt because one or more of the following conditions exist: Yes No the system is wit of a surface drinking water supply the system is wiet of a tributary to a surface drinking water supph the system is locitrogen sensitive area(Interim Wellhead ProtectionArea • IWPA) or a mapped Zonell ofapublic water supThe owner or operator of and• suchll bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (riviaad Page 3'oi 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARI B. ,;..:,Y: CHECKLIST property Address: Owner: V ,5 r. Date of Inspection: You must indicate either'Yes'or'No'as to each of the following: Check if the following have been done. Y No _ Pumping information was provided by the owner, occupant, or Board of Health. um for at least two weeks and the system has been receiving normal None of the system components have bee n p P� ing that period. large volumes of water have not been introduced into the system recently or flow rates dur as pan of this Inspection. _. As built plans have been obtained and examined hole if they are not available with N;A. _ The iac:ll� or dwelling was Inspected for signs o-sewage back-up.' ^ _ The s-,•stern does not receive non-sanitary or industrial waste flow. v _ The site %%as inspected for signs of breakout. ! _ :• +I Absorption System, have been located on the site. All systerr. corponents, excluding the So �. _ The septic tank manhoies Mere uncovered. opened. and the interior of the septic tank was Inspected for condition of dimensions, deptn of liquid,depth of sludge, depth of scum. banies or tees. materla`• o'cons;ruction. The size and location of the Soil Absorption System on the site has been determined based on- The r maintenance of _ The fac,lit, om ne• %ano occupants. If dlrteren: Irom owner) were provided with Iniormatlon on the p ope Sub-Suriace Disposal Svsterr.. Existing iniorrnation. Ea. Plan at B.O.H. y Opp Determined In the field !I,'an% of the failure criteria related to Part Cis at issue. approximation of distance is u^acceatabie (13.302.31;b'j Pago 4 of 10 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM-- OR 1 PART C SYSTEM INFORMATION Propert% Address. , Owner: ' Date of Ihspection: Slsl�p D FLOW CONDITIONS a RESIDENTIAL i Design floe. .p.d./bedroom for S.A.S Number of bedrooms Q Number o'current residents- Garbage ; r ' 8'�'der (yes or not: Laundry co:—ected to system (yes or-no). ` Seasonal use tyes or no!:- Water meter readings, if available (last two (2i year usage tgpd): Sump Pump (ves or no).—tO Lat, date o' occupancy y"NO-4.1 V S W � COMMER- i40NDUSTRIAL: Type or establishment Design fio%% _ galionsida% Crease trap present tves or no_ Indus;na! 1Naste Holding Tani; present."%ves or no -� ':onsanttan Haste discnargec to five Tr,,e S system. ;ves or no - • � " ' 1%ater meter readings. d aya,labie Las:pa;e o: o OTHER. De4cnbe Last sate o►occuoanc. = GENERAL INFORMATION PUMPING RECORDS and source o►tniormattor, - 'System pumped as par, of inspeaton: lyes or no° e y If yes• volume pumped- ¢allons _ - Reason for pumping TYPF OF SYSTEM ry Septic tankrd,stnbuuon box/soil absorption system T' Single cesspool Overflow cesspool �. Privy Shared system (yes or no) (if yes, attach previous inspection,records, if any) t I/A Technologv etc. Copy of up to date contract? Other - s APPROXIMATE AGE of all components, date installed (if known)-and source of information": Sewage odors detected when arriving at the site. (yes or not VQ ` (revised 04/25/91) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 11%'FORMATION (continued) Property Address: �Z) QnYautS� " Owner: J`p*1C 's Date of Inspection:5isl-78 _ BUILDING SEWER: _ (Locate on site plan) Depth below grade. -._. Material of construction. _cast iron _.40 PVC _other (explain) _•._ - Distance from private water Supply' well or suction IrsDiameter - _. . Comments: (condition of joints, venting, evidence of leakage:eic.) SEPTIC TANK: S tlocate on site p an Depth below grade- 1; glass polyethylene _othertexplain Material of construction: �concre-e _rr,e:a _Fioer a.. _ li tank is metal. lis: age _ Is age confumec o% Ce"t;iica:e of Compuance �(lresNo Dimensions Sludge depth u�t 4 Disiance from top o:A!udee to bororn o-outie: tee o, bade L_ Scum thickness yt Distance from top o: scum to top of ouile.iee or ba;:e Distance from bottom of scum to bo-o-n 0�outlet tee e- ba*.e Now dimensions were determined A41a&`r r,f etA-- Comments. inlet and outlet teesUr baffles. depth o'liiuid level in relation to outlet inv rt, structural trecommendation for pumping, condition 0 integnry, .•idence of leakage. e:c.i v GREASE TRAP: " O (locate on site plan! Depth below grade: 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: Comments: (recommendation for pumping, condition of islet and outlet tees or baffles, depth of liquid level in.relation to outlet invert, structura l. integrity, evidence oi leakage, etc.) (revised 04/25:97) Page 6 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO%.F0Rti1 Y i PART C SYSTEM INFORMATION (continued) Propert% Address: 13 r U kVC(t4 Owner: V1,Inu S n ' Date of Inspection: rSh # (locate on site Ian, TIGHT OR HOLDING TANK: 'r" A must be pumped prior to:or at time, of inspections p - i Depth below grade: Material of construction. _concrete g metal Fiber lass :-_Polyethylene y _other(explain) - Dimensions: _......- _ . - Capacm- gallon< Design flow galionwaa, Alarm level Alarm in working Order Yes. o Date of previous pumping — — Comments (condition of Inlet tee. condition o' a'a•m and float switches, etc.t DISTRIBUT10% BOX: Lim r^ (locate on site pia- Death of liculd level a00%,e outle: Irne'. Comments mote r.• level and distribution. _ eaua' evidence of solids carryover, e�-Iden a of leakage Into or out of box, etc.) ('��L� 't"'CL`1. * •kc� �'Z�lC c-t n /--lit— �R�- 1� . . t . PUMP CHAMBER: .._ R T (locate on site plan. i Pumps in working order: (Yes or No' . Alarms in working order (lees or No Comments: _ 1 (note condition of pump chamber, condition of pumps and appurtenances, etc.) b. (revised 04/25/97) pay• 7 of 10 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prope Addr-ss: S)C - Owner:V�fj f,US Date of Inspection: $ts1�C t SOIL ABSORPTION SYSTEM (SAS):—WA- (locate on site plan, ii possible: exca� .on not required. but may be approximated by non-intrusive methods) _ .. ... _ If not determined to be present, explain: Type.. leaching pits, number. 1ir,1. leaching chambers. number:_ leaching galleries, number. _ leaching trenches. number,length:__ leaching fields, number, di ne-isjo^.s overflow cesspool, number Alternative s\•stem Name of Tecnnolog\ Comments. (note condition of soil, s!gr•s of hydraulic failure, level of ponding, condo u on_of ve o , etc. ' - tae 1;'% CESSPOOLS: (locate on site plar. Number and configura:,on Depth-top of liquid to inlet Inver, Depth of solids lave- Depth of scum layer. Dimensions of cesspoo Materials of constructior Indication of groundwate- inflow tcesspool must De pumpeC as par, of inspection:! Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: - (locate o site plant " Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/91) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM' PART C SYSTEM [%FORMATION (continued',`,' Properh Add ess: Owner: Date of Ins ion: `a SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reierences landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) f V,L f 01!25/5') page 0 of 10. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertv Address Owner: `►IG`rc1S Date of Inspection: c Depth to Groundwater feet Please indicate all the methods used to determine High Groundwater Elevation:... Obtained irom Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions CneC� with loca! Board o• newt^ Chec'K FE.MA neaps Check pumping records Check local eacavato,s. installers t.se LcCc Data i o Descibe in voi, o%%". v.oros r.o•.• \o- es:acih5hed the !-iigh Groundwater Elevation. (Must be completed: lzav:aad Page 10 of 20 9 5 Ew A G E PE RMOT NQ• L:0 C A°T IONJp2/ VILLAGE - - -NSTALLER'S NAME 6 A ® DRESS _3l} .'•'ttlUi �i West Barnsta'b e, Mass. 02663 G U I L D E R OR OWNER DATE PERMIT ISSUED . -.t9 -�5- DATE COMPLIANCE ISSUED i i