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HomeMy WebLinkAbout0051 PRUDENCE LANE - Health 51 Pr6dence.Lane iA = 040.=_05� �Cotuit --- - -- - -- — Commonwealth of Massachusetts COPY Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. lns ector: only the tab key p to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name r� P.O. Box 371 Company Address Sandwich MA 02563 City/Town State Zip Code 508-888-6055 S1 12843 Telephone Number License Number B. Certification LU I certify that I have personally inspected the sewage disposal system at this address and that the C) 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 e — 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 p i t ❑t Needs Further Evaluation by the Local Approving Authority May 17, 2010 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. n t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewag Syst •131- of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 01 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. CityTTown 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: Property has been vacant for a year. 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 the replacement or repair, as approved by the Board of Health, will pass. Check the-box for"yes", "no" or"not determined" (Y, , ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* r the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltr tion or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is rep ced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspecti if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is ess than 20 years old is available. ❑ Y ❑ N ❑ N (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts R Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29 2010 every page. City/Town 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 placed ❑ 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(§) are replaced ❑ Y ❑ N ❑ ND (Explain below): t ❑ obstruction is removed ❑ Y N ❑ ND (Explain below): C) Further Evaluation is Req/fuer Board of Health: ❑ Conditions exist which requuation by the Board of Health in order to determine if the system is failing to proteh, safety or the environment. 1. System will pass unlesealth determines in accordance with 310 CMR 15.303(1)(b)that the systetioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water '❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29, 2010 required for p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorptio system (SAS) and the SAS is within 100 feet of a surface water supply or tributary a surface water supply. ❑ The system has a septic tank and SAS and a SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS nd the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and he 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 wat analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pr sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no ther failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) stem S Failure Criteria Applicable to All S Y pp stems:Y 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is P required for Lowell MA 01851 April 29 2010 every 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" o" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 0 feet of a surface drinking water supply ❑ ❑ the system is wi in 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is ocated in a nitrogen sensitive area (Interim Wellhead Protection Area—IWP ) or a mapped Zone II of a public water supply well If you have answered "yes" to ny question in Section E the system is considered a significant threat, _ or answered "yes" in Section above the large system has failed. The owner or operator of any large system considered a signifi ant threat under Section E or failed under Section D shall upgrade the system in accordance wit 310 CMR 15.304. The system owner should contact the appropriate regional office of the De artment. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 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? ® El 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 549 GPD f t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assess.Ments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29 2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 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 2008= 98 GPD g ( y g (gp ))' 2009=vacant Detail: Sump pump? - ❑ Yes ® No April 2009 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 itle 5 system? ❑ Yes ❑ No Water meter readings, if available- t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29 2010 every page. City/Town State Zip Code Date of Inspection D. System Information(cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No pumping records found 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Comrfionwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 10/18/84. As-built and engineered plans on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3,8,E Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3'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: 1 V X 5'X 4.5' 1500 gallons 3,1 Sludge depth: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness _ 011 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations,- inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet PVC tee and outlet concrete baffle in place. Liquid level 1" below outlet invert. Property has been vacant. No sign of leakage. Risers bring covers within 6" of grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglas ❑ polyethylene ❑ other(explain): Dimensions: Scum,thickness Distance from top of scum to top of out t tee or baffle Distance from bottom of scum to bo om of out tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, , liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank tank must be pumped at time of inspection) locate on site plan): 9 g ( p P P ) ( p ) Depth below grade: Material of construction: ❑ concrete ❑ metal /erglass ❑ 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: /. .- Comments (condition of alarm and float switches *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 Aril 29 2010 required for p � ' 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 011 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet. No solids carryover. No high water staining over outlet invert. Riser brings cover within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump/ber, ition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12 ' F Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: 1-6'X 6'w/2' of ® leaching pits number: stone. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1' of liquid in base of pit. 4' below invert. High water staining approx. 3' below invert. No sign of past hydraulic failure. Pit located and inspected with camara. 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•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraul' failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below El drawing attached separately l � O y I I t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells >4 Estimated depth to high ground water: 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: 08/25/83 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database explain: ma water usgs gov terraserver-usa.com You must describe how you established the high ground water elevation: No ground water found during test hole (1983). Accessed local ground water contours and topo mapping Base of SAS at elv= 55 Test hole elv= 51. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Prudence Lane (Main house) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments OR? 51 Prudence Lane (Garage) Cotuit MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29, 2010 required for p every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Importh t: WhenT!lling out.. A. Gleneral Information forms Oh-the �' F comp ter use : 1. Inspector: f only the tab keg' to movyour Patrick T. Sullivan _ cursor ado not:. Name of Inspector use the-return key. Ready,Rooter, Inc. Company Name f� F P 0 Box 371 Company Address 60 Sandwich - MA 02563 City/Town State Zip Code 508-888-6055 SI 12843 Telephone Number License Number B. Certification • t I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The system: ® ,Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ` -�✓' May 17, 2010 Inspectors 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•09/08 Title 5 Official Inspection Form:Subsurfac a age Di posal System Page 1 of 1 G f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell required for MA 01851 April 29, 2010 _ 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Property has been vacant fora year. 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 eplacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or a septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltrati or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is repla d with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection ' it is structurally sound, not leaking and.if a Certificate of Compliance indicating that the tank is I ss than 20 years old is available. Y ❑ N ❑ N (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 L Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 Aril 29, 2010 required for p every-page. City/Town 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed El ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or re ced ❑ 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 th Board of Health: ❑ Conditions exist which require furthe evaluation by the Board of Health in order to determine if the system is failing to protect publ' health, safety or the environment. 1. System will pass unless B rd of Health determines in accordance with 310 CMR 16.303(1)(b)that the system ' not functioning in a manner which will protect public health, safety and the environment. - ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3-of 3 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29, 2010 required for p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functi/SAS manner at protects the public health, safety and environment: ❑ The system has a septic tank sorpt n system (SAS) and the SAS is within 100 feet of a surface water suta to a surface water supply. ❑ The system has a septic tank the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank d the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SASAS 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 coliform bacteria indicates absent and the pr ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no o er 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell required for MA 01851 April 29, 2010 every 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 f et of a surface drinking water supply ❑ ❑ the system is within 20 feet of a tributary to a surface drinking water supply ❑ ❑ the system is locate in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or apped Zone II of a public water supply well If you have answered "yes"to any qu tion in Section E the system is considered a significant threat, or answered "yes" in Section D abo the large system has failed. The owner or operator of any large system considered a significant th at under Section E or failed under Section D shall upgrade the system in accordance with 310 R 15.304. The system owner should contact the appropriate regional office of the Departm t. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 5 of 5 II Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell required for MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 2 ❑ 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 GPD t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 51 Prudence Lane (Garage) Cotuit MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell required for MA 01851 April 29, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 2008= 98 GPD g ( y g (gpd))' 2009=vacant Detail Shared meter with main house. Sump pump? ❑ Yes ® No Last date of occupancy: April 2009 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/system? Grease trap present? ❑ Yes ❑ No Industrial waste holding tank presen El Yes ❑ No Non-sanitary waste discharged to th ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 fficial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit, MA 02635 - Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29 2010 required for p , every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No pumping records found 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8' L Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29 2010 required for p every page. City/Town State Zrp Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 08/23/85. As-built and engineered plans on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2,8„feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 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-copyof certificate) ❑ Yes ❑ No Dimensions: 8'X 4.5'X 4.5' 1000 gallons Sludge depth: 311 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29, 2010 required for every page. Cityrrown 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 32" 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 28"Tank half full Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet PVC tee and outlet concrete baffle in place. Liquid level 2' below outlet invert. Property has been vacant. No sign of leakage. Risers bring covers within 6" of grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fibergla ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outl tee or baffle Distance from bottom of scum to bo m of out tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Garage) ._Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: , y Material of construction: El concrete ❑ metal ❑ fiber ss ❑ 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 o alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No. t5ins 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 l . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29 2010 required for p 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.): One inlet, one outlet. No solids carryover. No high water staining over outlet invert. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, co Ition of pumps and appurtenances, etc.):. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'X 6'w/ 1' of stone. ❑ 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.): Leach pit empty at time of inspection. 4' below invert. No sign of high water staining. No sign of past hydraulic failure. Riser brings cover within 6"of grade. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydra Ic failure, level'of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 it ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ��► �� S 4 � t � Q . Q t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 l_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is Lowell MA 01851 April 29, 2010 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: ,4feet 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: 08/25/83 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) Accessed USGS database-explain: ma water usgs gov terraserver-usa.com You must describe how you established the high ground water elevation: No ground water found during test hole to14' (1983). Accessed local ground water contours and topo mapping Base of SAS 8' below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M " 51 Prudence Lane (Garage) Cotuit, MA 02635 Property Address Robert Fairbank 173 Foster Street Owner Owner's Name information is required for Lowell MA 01851 April 29, 2010 every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 W Fzz THE,COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... --------- ..........OF.........................:............................................................... Y ApplirationJor Diiipaoal- lVarkii Tonarurtion ramit Applilation is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .......... ... . .................. ...T--- .......... Location LAddress or Lot-No. ..tL.^s-=a......t.. ... ............................. ........................................... 1', Address ..................................................................... Installer Address Type of Building Size Lot_ 7...... .Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ...aA9_4_CiA.E_No. of persons.........4=:: ............. Showers Cafeteria ( ) Otherfixtures .............................................................. .................................................................................. Design Flow........ ..................gallons per person per day. Total daily flow................... .........gallons. Septic Tank—Liquid capacity.IP-CZ)gallons Length-----a.l.. Width.. Diameter................ Depth_..5........ Disposal Trench—No..................... Width_._..._.._...____... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No............. Diameter..'___::.: .... Depth below inlet....G............ Total leaching area..z9..�...sq. f t. Z Other Distribution box -Dosing tank Percolation 'rest Results Performed by._..__�.:7FA..I ?..p .Q.k........................ Date....S,l?�../8 �._..... Test Pit No. I...C:7?�__.minutes per inch Depth of Test Pit..... Depth to ground water.__. 6N F fi Test Pit No. 2................minutes per inch Depth of Test Pit__.___.__...____.__. Depth to ground water....._...._......_.._-__ ......................................................;...................................................................................................... O Description of Soil........... ........ .....77P....... ."­C. �A.v.P. ....................... �4 ............................................................... ----------------*.............*-------*......**'*"*----------------------------------­_­----------*------------------------------ ................ ..........................................................;....................I.........................................................................I....................... U Nature of Repairs o,rAlterations—Answer when-applicable................................................................................................ ........................................................w............................................................................................................................................... Agreement: The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I TALZ 5 of the,State Sanitary Cod h nders' ther agrees t to place the system in \operation until Certificate pf Co pliance has be iea hance "a' SSigned........ ............ ............ . .................................. ............. .......... Date A pplication Approved By............ ...... .. ....................... ............ Date Application Disapproved,for.the o owing reasons........................................................................................... ..................... .....................................................................................................................................................................w.................................. Date PermitNo.............................. ...................... IssuedL....................................................... . Date ism ANA ��`F"R.i� - `�'. 4y`��A. �.. _ � C('.� � �C`.�;. L 1 �•�4fJ..���`I .. Y - ".��,.. h� ,,w:.• ....sue �,. s- �' No.. -.V'.____..5� FEs......L ............_. L THE COMMONWEALTH OF MASSACHUSETTS a 7 BOARD OF HEALTH ....... .. .. ... ,.....L.OF............................................................................ ApplirtttiPu for Dhip ml Workg Towitrur# un Permit Application'is, hereby made-for a.Permit to Construct ( ) or Repair ( ) an Individual^Sewage Disposal System at. 1 E 1Jc ►JE Ca ............... ...__. l7... . ? ------.-A - ---- "A..................................... Location-Address 4 or Lot No ............... ......'. ...` .. A•1J ... ..._............................................ ner Address a ................. �....... - " .............. �� . -- ........: ...... ...... ---•-•-•- ------ Installer Address Type of Building Size Lot... feet Dwelling—No. of Bedrooms................... ... .............Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building _....._. Showers a Other—Type g ._C�.�>z aG:�NO of persons _..:_.« ( ) Cafeteria QOther fixtures ..... . •-_.. ....--•--------- W Design Flow........ _. 47 :.gallons per person.per day. Total daily flow ?Z 4;>........gallons. WSeptic Tank—Liquid ca.pac ty taCX7gallons Length.-_._a...... Width Diameter:-................... Depth...5........ x Disposal Trench—No. .................... Width..................... Total Length _- Total leaching area....................sq. ft. Seepage Pit No.............,....... Diameter. .....�_... Depth below inlet.__�r_:............ Total leaching area_.zv.1...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) A�A_3 Percolation Test Results ZPerformed by...._. . t !'►�.Cz 3 ! _ . ....._.: Dat8e._.. ... Test Pit No. I.,.<.. minutes per inch Depth of Test Pit..... Depth to ground water_ til... . �. 4. Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water.................... ... . . •--...._ .... ..-----•.................... ...... ------•- ......................................... O Description of Soil G c ca 2 IE__ 1 V A V ------------- •----•-•--- UNature of Repairs or Alterations—Answer when applicable.............................................. . .....: r ` ....................._..... -----------------------------------•------•------••--------•-----------••---••------...--•-•-----...--•---------------------•---•-----•------•------------------------•-----•-•-----•--•-------......... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL,Z 5 of the State Sanitary Code"— The undersi d f ther agrees t to place,.the system in operation until Certiti to: f Compliance has bee t o i Signed------. .. A lication A roved B ........ ~ Date PP. , PP Y------- ..._.. !... .. DaZ- S te Appl cation Disapproved for the o owing reasons:.._ :.. ..--- --------------------- ---•-• -------••-•--•-- ...................... ..................... .... -•--•. _.._... ........ .. ._ ........................................................ Date Permit No................................. ............ Issued._. Daft ............ _.�:� . __.,._........................... _._ .:4ti �.n __ _ ......... THE COMMONWEALTH OF MASSACHUSETTS Al BOARD OF 'HEALTH ..........................................OF... ........ ....... ..................................... Cgrrtifiratr of Toutpliatirr THIS IS TO CERTIFY, T t nu vid e z e Disposal System constructed { ) or Repaired ,A�llii �}�} by '.................................. :--•- ....................................1 ` � l�..---•••----•-..........-----------.--.:.. .....-----.._........ ............... k Installer �u at l--•-•......... :R .4.D-1 tl)4Ct. .....L, 1 : .._..:_.�.p"x"v I....----•-•._..... has,been installed_in accordance with thenrovisions of TITLE 5 of The State Sanitary Code as described in the ap eation for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEIN WILI, fU CTION SATISFACTORY. R DATE..:. _°Z3_.. .• ' ....:. Inspector.. ....... k�--�` Z4 THE COMMONWEALTH OF MASSACHUSETTS f BOARD OF HEALTH ..........................OF......... ....... ......... ......... FEE. Dispolia Works Toptrwtion Fermi Permission is hereby granted____________ ___ A-----D-------------.©.w ' _!� _ to Construct ( ) or Repair ( ) an Individual Sewage,,Disposal System Street as shown on the application for Disposal Works Construction Permit No................ __ Dated /p ....... ..... e . �6 -----------oar o .Heal DATE. "� - (hop M46 L-56 17 ( LOCATION ' g� SEWAG PERMIT NO. VILLAGE I N S T A LA ER' ME i ADDRESS ago.- `e?UILDER OR OWNER I � DATE PERMIT ISSUED s DATE COMPLIANCE ISSUED ou 0 ' 4 I i 0 /OU D Ak e z No.._. :: . . Fps...2 _............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH " - b U..► . ..................OF.... I .T�-.P `�.TI - ._�f.................... Appliratiou for Disposal Works Toustrurtiuu tIrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Locatio -Address_ or Lot No. Owner Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( a Other—T e of Building ............... No. of persons....._......._.._........___ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow............ ?.....5.5-------gallons per person per day. Total daily flow.................... ................. ....... gallons. WSeptic Tank—Liquid capacity.UK6O.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching a ea____.._____.__._.._sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date-----------------------••--------------. i� Test Pit No. 1...._...Z....minutes per inch Depth of Test Pit...-t ��---_-.. Depth to ground water.....QjM _Fyz f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .•---------•--------••--••---•-••----•..................................•• . ....._.....•---•-----•-••••---••--•-----•-•-•-----:........•-••---••-•----.-- O Description of Soil........... : _!!I4?.------..a, �-�.r':. ._ ..... M' ` v"... U -------------•---•......-----•----- W x -----•----••---------------------•----•--•-•--••---•----••---•--...-----•••---•-•--•------••----•--------------••--•-------•-----------••--•------•-••-------••---••-------...------...----••-••-------- 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 TL I 1�U 5 of the State Sanitary Code— The undersigned further agrees not to place the system'in operation until a Certificate of Complia e has be ssued by the board of health. Application Approved B /Z�/ PP PP Y . -...._... ----•- Date Application Disapprove or he following reasons---------------------•--•----•---------------------. ............................................................ .............................. ...............••------------------------•...---•••-----•------------------.....••--------•---•----------•----•....------•---•---•---••-------•-----•-•---•---•-•---•--- s Date Permit No......................................................... Issued_....................................... :_ Date ----- - 4 S� No.... -.r Fss........................... THE COMMONWEALTH OF MASSACHUSETTS ` ... BOARD OF HEALTH CAW..A1..................OF.....5-A,-�.&�.5.7-T—) ...k E .......... Appliration for Disposal Works Tonstrurtiun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -. Location-Address or Lot No. ......... . k.� 1-, =-m'.Z... ....�^'.e ..1. .1 .t,�.� . �,(�. .1 .b -OS tr: . Owner Address ---- .- p.. .....��'. .�...!:�...r-: ,�?. .................... ....................C-•----------------------------------------------------------•------------ Installer Address UType of Building Size Lot............................Sq. feet .--I Dwelling—No. of Bedrooms...._ .............................Expansion Attic ( )- Garbage Grinder Other—Type of Building . No: of persons............................ Showers a YP g ---------------•--..:------ ----•P--�- ( )--- Cafeteria-( ) Otherfixtures ..........................-- ------------ ----•----...---------•--•----..._.................-----...-- ...... W Design Flow...........5199.44....S!Z-----gallons per person per day. Total daily flow..................:75_73.-0.......gallons. WSeptic Tank—Liquid capacity.15.40.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................ Date........................................ Test Pit No. 1_t-�._•_ ..minutes per inch Depth of Test Pit.j(:0JB..'.. Depth to ground water..__�p_�.�..F�� fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... ,Depth to ground water........................ a ---------------------------------------------------------------------------------------------------------......... ...----.....--------------------------- O Description of Soil------....��. .Ll.�7t:. .�- .5'i• ....... : ._t-:u- w VNature of Repairs or Alterations—Answer when applicable............................................................................................... ...----•----------------•----------------...........•..---------------.....--------•-•-...........-----•------•---------------------....--------------------•------------..........------•--•-•--•---_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complia - has bee ' sued by the board of health. Signed .......................................... .................................... ........... Application Approved BY - ----------------••----------.....--------••-•--•-•-•-•.........: :_ - In - I ................ Date ...--•------ Application Disapproved 'r e following reasons:.............................................................................................•----•-----.-.._. •-----------------------------------------•--•-..,.-----,--...---------••-•-----..............-------------........-----------------------------------------------•------....-----------------------•--- Date PermitNo........................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l, ..........................................OF..................................................................................... f1rr#ifirtt#r of f�laut�rliunre TH IS TO C_ FY, That the Individual Sewage Disposal System constructed or Repaired - -- g P �' ( ) ( ) by............ : .... ----•-------------------------------------------------------------------------•---.--•--- has been installed in accordance with the provisions of TI F 5 of T e State Sanitary d as /bed in the . application for Disposal Works Construction Permit NO.. �' .% ._........ dated_. . f_ r...................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................••---•......••--..../0 -146 1 eel. Inspector...........•�7:- •----•---------------------------------•••..........-•••••••. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 F..................................................................................... ...................... FEE... ................. t ti'sa ' nrk D[n rttr ilan lerutt Permission is hereby granted.... to Construct ( Ind' a' S rage Disposalz st em atNo.. t� .✓fir LP `!(----------------------------------------------•----------...--••----••-•---- Street • as shown on the application for Disposal Works Construction Permit No...__ Dated.......................................... ..........•-_.0_ . ............................................................ / o y Board of Health DATE.................. S l FORM 1255 A. M. SULKIN, INC., BOSTON LO CATION SEWAGE PERMIT NO. VILLAGE 6�rytTI "P INSTALLER'S NAME i ADDRESS R U I L D E R OR OWNER DATE PERMIT ISSUED 15 A�.� �- DATE COMPLIANCE ISSUED CwL OA V` 2 1, \$ti ig APPLICATI,GP FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION `�Jo r�de,�� (-c� v NO.Z VILLAGE _Q �/U -0�1 DATE - APPLICANT '�,c �, do 2 ►6 p._�►J(c FEE 2 t� ADDRESS �a s-�"t' TELEPHONE NO. (Non-refundable) ENGINEER TELEPHONE NO._'36-2- --1 I DATE SCHEDULED Oy (Applicant' s signature) O O O O OO . • . O O ! O O . • • . . • • O C O • O . . . • . . . • O . • . . •.. . O • . . . O . . . . . . . • O • O . • • . • O . . O . • . . . . SOIL LOG SUB—DIVISION NAME Co 4 S DATE :5%PT 28 t`78?7 TIME EXPANSION AREA: YES V" NO `� 1- +zf3raovl� ENGINEER::?�; TOWN WATER P PRIVATE WELL J, co BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc. ,dimensions .of° lot, exact location of test holes and percolation tests, locate wetlands in proximity to test' holes ) NOTES: f I zo ' UJ J �f ji) z S L' o-F v .Z moo' L o T-. PERCOLATION RATE: Zvi��ih S <�� ►"� �� �'`�� TEST HOLE NO: F ELEVATION: SS,b TEST HOLE NO: ELEVATION: 2 :. �3 �3 , n 2 • 3 3 4 4 - 5 Q 5 6 6 7 7 8 8 10 10 11 11 12 12 13 i- o 13 ,, 14 �� 3/,(� �/ 14 15 p �� 15 16 16 C� SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD EACH G PITS , LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P . . AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT I\ �, A C ^v :s , r r TOWN OF BARNSTABLE LOCATION 0 c�;..��-e L���,� WAGE# VILLAGE ��U ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 1CCcz�en LEACHING FACILITY: (type) L�,��`,�, .pT;\ (size) ( �k fQ NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: 2-Z 0 W�Ct Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility " T Feet Private Water Supply Well and Leaching Facility(If any wells exist e on site or within 200 feet of leaching facility) rA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY'�;2,e. � gvsa:,Q., 1 i a r - 4OL O A : i i � t i TOWN OF BARNSTABLE LOCATION rS1 PVloa, a W GE# Pd'U rah c°td wP r. VILLAGE ASSESSOR'S MAP&PARCEL OV0 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY S"UJ �.►r jc» S LEACHING FACILITY:(type) (size) Co' NO.OF BEDROOMS �A " OWNERb��� PERMIT DATE: y // COMPLIANCE DATE: /O Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ``I Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) -� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) A-116 Feet FURNISHED BY ti)r,.�r roaW.\ � 1'a\�rV� � — — — — — —� '� �� � � t � gig` -,� , : �a � 4 � �F`�l`► ��- for ► �� ,1 1 t � SECTION - SEWAGE I Cp, -SEPTIC TANK - C, - "D"BOX - - LEACH �' I TOP OF FDN (MSL)# "2"OF,iaTO ih" WASHED STONE \ :V �`�•M..4�M ^`Ys,4 'r. �+ ►}�+.-.� 3 � Y.• � � V _ w'4"a�Y.'f IN OUT- IN- 1 1 K.,.."'"r".+ �• �... 1 ` . . .a- f OUT IN T ELEV. TASEPTNK- ELEV. ELEV. ELEV. ELEV. ELEV. �. OF b" lre' t , DLO QQQ . WASHED STONE i ��'j/ \ 1' dam• ^`!M�r 1 TEST HOLE LOG ' -TocuNoaT,ri� TEST BYYL+t (rlrtal)�1' WITNESS TE T DATE S/Z S/� S '�_ �'Z,3 DESIGN �- BEDROOM HOUSE z T.H. 1 T.H. # 2 ELEV.e©S-Q ELEV. NO { � PERC RATE G �- MIN/IN. DISPOSER DISPOSER �JVV 4 FLOW RATE Z'LC>(GAL./DAY > w (ra`s SEPTIC TANK ( )_ l1 Hlr�, REQ'D SEPTIC TANK SIZE I 1 S S r Kr LEACH FACILITY r' .�4I+9�3 +��'' � 4t, L) SIDE WALL 4 * i 0-yj= 188' �( Z,S) 4-1 1 G/D. f� BOTTOM $I- ,IT 16E3 s�,h. Sl. p TOTAL c 2G,1,oc USE: p IJ+G LEACHING - NC� WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) + Go v i t\� OF 1. DATUM (MSL)-TAKEN FROM ._______-.___�.-_____r--__________QUADRANGLE MAP rL 2.MUNICIPAL WATER----------......_!_- __.-_-______-____ ___AVAILABLE ���/ 11V 3. PIPE PITCH: V4"PER FOOT G� RICNARD 4.DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO_ 1 a -44 _ R. �` ! 5.MIN. GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. ---0-DISTANCE AS CERTIFIED 6. PIPE JOINTS SHALL BE MADE WATER TIGHT 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. STATE ENVIRONMENTAL CODE TITLE 5 No �� Ox + SITE PLAN i^^ I HEREBY CERTIFY THAT THE BUILDING SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON &THAT IT _ LOCUS: �• �' CONFORM TO THE ZONING BY LAWS OF THE Ce3TvII- C,� TOWN OF G. PROFESSIO AL ENGINEER WHEN CONSTRUCTED. DATE ZZ S%A 17 •� downCif've eniv lleefil PRFPARFD FOR ��i_�A-12�3ta--►,�t�r- - �" CIVIL ENGINEERS LAND SURVEYORS BOARD OF HEALTH REG. LAND SURVEYOR CONTOURS (EXISTING)-•-- c� (PROPOSED)-0--0-0�- S APPROVED DATE ''�N��'� � MA. Yarmouth&.Orleans,MA SCALE DATE 7