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Home My WebLink About0032 BOB WHITE CIRCLE - Health 3ZBOB WHITE CIRCLE ► , , x ®STER�II�I.E A = +a9, e a 0 1 rpoA-ei61AL Commonwealth of Massachusetts uEK0599Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM 3ey`0 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC 110 Owner Owner's Name I„-h information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Charlotte Phillips use the return Name of Inspector key. Speakman Excavating LLC �-V Company Name 15 Speak Way Company Address Harwich MA 02645 Cityrrown State Zip Code 508-432-5565 SI 14065 Telephone Number License Number B. Certification 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 ❑ Need Further Evaluation by the Local Approving Authority Ins i' p S. nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form E Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 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: ® l have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no'' or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 6 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 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owners Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont:) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine_ if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.3/13 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts _ 4 a Title 5 Official Inspection Fora. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 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 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owners Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. Citylrown 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. ❑ Z 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 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .•°`V 32 Bob White Circle, Cistervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 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 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: a201(o , mUoo Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•:3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts 4 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'� 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 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: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 40"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 101+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Bldg sewer in good condition, no signs of leaka e. Septic Tank(locate on site plan): Depth below grade: 12„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: 1000 Sludge depth: 4" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 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 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" 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.): Tank in good condition, no signs of leakage or failure. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Bob White Circle Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow; gallons.per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): 1. Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is 33 Prince Rd required for every , Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box in good condition one outlet from d-box to leaching pit Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owners game information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Type: ® leaching pits number: (1) ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): (1) leaching pit in good condition, current liquid level 4' below invert, no evidence liquid has been higher. Permit taken out 3/30/98 indicates 5 infiltrators to be installed no evidence of infliltrators having been installed. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 32 Bob White Circle, Cistervile Property Address I Cape Cutham LLC Owner Owner's Name information is required for eve 33 Prince Rd, Yarmouth MA 0267 every 3 10/18/17 page. Cltyrrown 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.): t51ns•3113 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 5••'•v 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owners Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. Cityrrown State Zip Code Date of Inspection D. System Information 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 Bobwhite Circle Water Service 22 3 49 3 41 �a'arf� 57 .i 07.244 Khouri.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Oisposal System,Page 14 of 15 , Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Bob White Circle, Ostervile Property.Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: i ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 25' below bottom of pit feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Per Inspection report done on 12/5/2007 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bob White Circle, Ostervile Property Address Cape Cutham LLC Owner Owner's Name information is required for every 33 Prince Rd, Yarmouth MA 02673 10/18/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's dame information is required for 31 Twitchell Street, WellesleyMA 02482 December 5, 2007 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. Important:When filling out A. General Information L-\� , forms on the computer,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 rQ 189 Cammett Road Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508-428-1779 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority December 5, 2007 Insp ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approvi. Authori Boa@d, of Health or DEP)within 30 days of completing this inspection. If the system is a s red sym o t has a design flow of 10,000 gpd or greater, the inspector and the system owner sh II submft , report.to the appropriate regional office of the DEP. The original should be sent to e systel own' ftrl and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions a h t the time of inspection e an d under heconditions-p Yt 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. 07-244 Khouri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is 31 Twitchell Street Wellesley MA 02482 December 5, 2007 required for Y 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: ® 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: Leaching pit had never had more than 18 of standing water and tank had liquid only. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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 ❑ obstruction is removed 07-244 Khouri.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 32 Bobwhite Circle, Osterville MA 02655 _ Property Address Lillian Khouri Owner Owner's Name information is required for 31 Twitchell Street, WellesleyMA 02482 December 5, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled 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 replaced ❑ obstruction is removed ND Explain: 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 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. 07-244 Khouri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is required for 31 Twitchell Street, WellesleyMA 02482 December 5, 2007 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 El ® 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. 07-244 Khouri.doc•08/06 Title 5 Official Inspection Form:Subsurface -Sewage Disposal System Page 4 of 15 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is required for 31 Twitchell Street, WellesleyMA 02482 December 5, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No El ® Any portion of a cesspool or privy is within a Zone 1 of a public well. 0 ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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 . ❑ Elthe 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. 07-244,Khouri.doc-08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is 31 Twitchell Street, Wellesley MA 02482 December 5, 2007 required for Y 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? El ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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)) 07-244 Khouri.cloc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is required for 31 Twitchell Street, WellesleyMA 02482 December 5, 2007 every page. Cityrrown State Zip Code Date of Inspection 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 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 d 1000 gal. 9 ( Y 9 (gp ))� Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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: Last date of occupancy/use: Date Other(describe): 07-244 Khouri.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is required for 31 Twitc' Y �hell Street, Wellesley MA 02482 December 5, 2007 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: • Source of information: None . Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons Howwas 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes No 07-244 Khouri.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a,••'` 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is 31 Twitchell Street, Wellesley MA 02482 December 5, 2007 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 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): Depth below grade: r 8 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: 0 11 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Visual 07-244 Khouri.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is required for 31 Twitchell Street, WellesleyMA 02482 December 5, 2007 every page. CitylTown State Zip Code Date of Inspection i 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.): Tank had liquid only, no solids. Baffles are intact and clear, tank is not in need of pumping at this time. 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 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): 07-244 Khouri.doc•08/06 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , e . 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is required for 31 Twitchell Street, WellesleyMA 02482 December 5, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 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.): Liquid level at bottom of single outlet pipe with no solids or high stains. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 07-244 Khouri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is 31 Twitchell Street, Welfesle _MA 02482 December 5, 2007 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: 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.): Leaching pit was found empty at time of inspection with a high stain line indicating pit had never had more than 18" of standing water. 07-244 Khouri.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Klhouri Owner Owner's Name information is 31 Twitchell Street, Wellesley MA 02482 December 5, 2007 required for Y i every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 07-244 Khouri.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts f4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Bobwhite Circle, Osterville MA 02655 Property Address -------- ----..----- ----- ----------—------- Lillian 'Khouri Owner Owner's Name information is required for 31 Twitchell Street, Wellesley MA 02482 December 5, 2007 eve City/Town/Town --... - --- ry page. Y State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. Bobwhite Circle Water Service 22 3 49 3 41 57 gA 07-244 Khouri.doc•08/06 1 oe 5 Official inspection form Subsurface Sewage Disposal System•Page 14 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e a,•'�- 32 Bobwhite Circle, Osterville MA 02655 Property Address Lillian Khouri Owner Owner's Name information is 31 Twitchell Street, Wellesley MA 02482 December 5, 2007 required for Y every 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 ground water: 25 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board.of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 10 and topo map shows property above el 40 07-244 Khouri.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Town of Barnstable Op 1HE 1p� Regulatory Services BMWSTABM + Thomas F. Geiler, Director Mnss. , �$ i639. A Public Health .Division ArF�MAy Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future- nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at_a particular property would-be listed on the"Disposal Work Construction Permit'. If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. i t TOWN OF BARNSTABLE LOCATION X�c bt�J�no�� r S&Wa46E4'nS� .'VILLAGE C (V 11C ASSESSOR'S MAyP,&PARCEL IId�S NAME&PHONE NO. SEPTIC ® a �1 LIPS-1-7� SEPTIC TANK CAPACITY OoC-1 LEACHING FACILITY:(type) ' ' (size) boa N0:OF BEDROOMS 3 OWNER. PERMIT DATE: C DATE:�r.SPor� ►o1ISb1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 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) Feet FURNISHED BY Bobwhite Circle a Water Service i ......:..::�x�..... ..... ......... .........................................................5..... ............................................................................ ........................................................................... 22 39 49 39 41 57 TOWN OF BARNSTABLE CC LOCATION �Sr SEWAGE'# '� VILLAGE r2 y ASSESSOR'S MAP & LOT Z-10-I°>l 2 INSTALLER'S NAME&PHONE NO. 'SEPTIC TANK CAPACITY LEACHING FACIL=:.(type) NO.OF BEDROOMS 3 BUILDER OR OWNER d[J IZ q PERMTI'DATE: .9' 'y 1 COMPLIANCE.DATE: Jy ` Separation Distance Between the: . Maximum Adjusted Groundwater Table_and Bottom of Leaching Facility Feet Private Water Supply Well and Facility �pp y g ty .(If any,wells exist �. on site or within 200 feet of leaching facility) - `. Feet Edge of Wetland and Leaching Facility(If any,weilands'exist" within 300'feet of leaching facility) A/t- --'"'" Feet Furnished by /tJ ,... K `t 4�{fit§ t No. .. I Fee��Q °— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for ;Dt5poga1 *pgtem Cotr9tructton Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location at Address or ot_N !.t Owner's Name,Address and Tel.No. +- Q Assessor's Map/Parcel (, g vU 1 t\ D �-�w t��- � �Z Leta Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 p ktr%,_ — KC4- o243o Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Rf�airs or t ation (Answer when applicable) I zu 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 provis' Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i ued b th s Boa;SLplalth. Signed Date Application Approved by Date Application Disapproved for theYollovNng reasons Permit No. d Date Issued No. / Fee "_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migpomt *pgtem Congtruction- Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or„Lct_No. , ,w 1',,:_7�, � �,,',.y. Owner's Name,Address and Tel.No. Assessor's Map/Parcel j u�UUrl��Z Lv(�Die 1 � 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ` Type of S.A.S. Description of Soil q- Nature of Repairs or lte ation (Answer when applicable) 1 1 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 provisKiue)db tle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been th's Boars f alth. Signed �� ems: Da_te� ?� —,28= 9r Application Approved by V,14,54 Date 2el�-- Application Disapproved for the ollo ng reasons Permit No. � � Date Issued -- — r. - -. -- ---- *---.------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certif ie� 'fe of! Comp ._ �-. � THIS IS TO CERTIFY,that the On-site Sew�ge Dispbs shin Constrt4 to ( ) Repaired(`�Upgraded( ) Abandoned( )by �J atM ` !�' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.&_/ 9.5 dated Installer c an Designer The issuance of this permit shall n be'construed as a guarantee that the system i11 tction as designed. Date ,3a - � Inspector No._ Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS M-5P05ar *pgtem Congtruction permit Permission is hereby granted t onstruct( _ )Rg it( . Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit,The applicant recognizes 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. Date: (, Approved by i I0/9197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) �a hereby certify that the application for disposal works construction permit signed by me dated M _ 2 9 concerning the property located at meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system There Is no increase in flow and/or change in use proposed a There are no variances requested or needed. if the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the --- proposed leaching facility will nDI be located less than fourteen(14)feetabove the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) DATE: SIGNED LICENSED SEPTIC YSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed Installer posesses a certified plot plan, this plan should be submitted]. q:health folder.art r< r^ TOWN OF BARNSTABLE (U�., „ SEWAGE #" :`LOCATION • <'`;VILLAGE '� — _ /t ASSESSOR'S MAP &LOT Lt0-l4� : : .IlJSTALL,ER'S NAME&PHINO. ' :�SEPTIC TANK CAPACITY mo 3 �k �� CILrN- (type) .. CHIN G A tYPe NO.OF BEDROOMS— BUILDER• �C � bvrZ 1 '?B:UIL.DER OR OWNER PERMIT DATE: i' � U COMPLIANCE DATE• 'Sepazadon Distance Between the: Table and Bottom of Leaching Facility g Feet .-Maximum Adjusted Groundwater '::,::::Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) :` Edge of We and Leaching Facility(If any wetlands exist N�r Feet within 300 feet of leaching facility) Furnished by ---. { -zv= � _a I � z • 1 9 • I '{ L0CA�TION?� SEWAGE PERMIT NO. Lod /I VILLAGE 6s7'L'Or- Ili A = 12o �4Z I N S T A LL R'S , NAME ADDRESS t C C2 Q U I L D E R ON OWNER DATE PERMIT ISSUED �� Y' DATE COMPLIANCE ISSUED S' ,,�,, � , ��' No............U.•. 70 Fss.._..... ............. .- THE"COMMONWEALTH OF MASSACHUSETTS • �� y 3BOARD OF HEALTH �. . Appliratiou for Diapoml Workii Towitrur#ion ramit Application is hereby made for a Permit to Construct (i0) or Repair. ( ) an Individual Sewage Disposal System at: . .._l L ' i�-� U..' ..................................................... ........ Location:Address or Lot No. L %V c�' !�!.ow l_ 1 ..................... L /'x r�1!v d S 111 i1 ...................................... W Gl `•� f v r lf�'1.rC��/. - es"s aller Address Q Type of Building Size Lot___2�.__GJ__-:.�_Sq. feet Dwelling—No. of Bedrooms.............. ______.___�___________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria a g fi t res .__._._.._. Design Flow_.- they _9 gallons per person per day. Total daily flow-------------- ...............goons. W WSeptic Tank—Liquid capacity __._gallons Length_�l_1_Q____- Width________________ Diameter--------------.. Depth................ x Disposal Trench—No..................... Width.................... Total Length........... .. Total leaching area....................sq. ft. � _ Seepage Pit No----------- --------- Diameter....L ._ ____._. Depth below inlet_________..... Total leaching area_ ag__sq. ft. Z Other Distribution box Dosing tank ( ) '"' Percolation Test Results Performed by.lLU 1. ,. .. (R1�`____________________ Date_.___ ____...- ►.� � 2 � Test Pit No. 1________________minutesper>nch Depth of Test Pit.._2________________ Depth to ground water.__ (i, Test Pit No. 2__..............minutes per inch Depth of Test Pit.................___ Depth to ground water........................ a ........................................................--- *-----------------"------ --------------------" -- - 0 Description of Soil----------------� �1......--1�--. ��-z�.�_-(� Q�I - x U ----------------------------------- ------------------------- ___....... _------------------------ __------------------------------------------------------------------------------- •---------------- W -------------------------------------------------------------------------------------------•-••-------------•-------------•-•-------•------•------------• --------................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Indio• ual Sewage Disposal System in accordance with the provisions of TIT E 5 of the State Sanitary e— he e si ned further agrees not to place th system n operation until a Certificate of Compliance has be e e d of health. Signed----- ---------- --- ------- .._..•-------------••-•-••-••-- Application Approved BY =---•-------- -- ...... ----------------------• a ..... `--- r Date Application Disapproved for the following reasons--------------------------------------------------------------------------------------------•.--•---------•_...._ Date PermitNo.......................................................... Issued...................... ............................... Date Y ' �S No................-....... FEs............................ THE COMMONWEALTH OF MASSACHUSETTS B®A R® OF HEALTH Applira#iun for Biupugal Works Tnnitrurtinn Prrutit rApp'Iication is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: L-7 1( i�v-p w4-Al s 62 1L.l ................__.............................................................................. --.....---......-•----••---•-----.._..-•----------..............••-------•--------.........-----•- tlif G''L Loca$ion-Addr ss� � •- --� 1�2 ,orLo�Nof'C --- i C/{%l. � •LCW`� J 1 tj �J ...........r._._......_...................................�-•--•I -•----•--•--- Owner Address W Installer Address / U Type of Building Size Lot_ Z ! --- ` ...Sq. feet a Dwelling—No. of Bedrooms......___...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type. of Building ____________________________ No. of persons............................ Showers ( ) Cafeteria ( ) d Other res . ---------------•--------- Desi n Flow___:_ .................. ___ _ � � W g ______________ gallons per person per day. Total daily flow.............................. _____.________gallons. R: Septic Tank Liquid capacity gallons Length .!. ____. Width________________ Diameter__._____________ Depth____________................. Disposal Trench—Nq_ ____________________ Wi th_,_______._._.__.__ Total Length.................... Total leaching area_ Jl��__,____......sq. ft. Seepage Pit No................ __ Diameter._ 7............ Depth below inlet__`T�_______.___. Total leaching area"-l�:_a._.sq. ft. z Other Distribution box ( ) Dosing tank ) ~' Percolation Test Results Performed byUv'��'.__�'__�... �G_____________________________ Date.___ ......... :. ..... c Test Pit No. I________________minutes per inch Depth of Test Pit___2__............ Depth to ground water:_---______________- G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ......___-----_ ---T _ _ -__._____.._......_.. __ ® Description of Soil..............D. �� J �! . ---- x 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 ("1 T/'1 I TTL the provisions of T _ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certincate of Compliance has been issued by the board of health. Signed --- -- ----------------------------------------- Date y �v Application Approved B -•-•---•--•. ' :�.'�-------•............... - a"br .,--z- ......._�•--- Date Application Disapproved for the following,reasons---------------•------------------------------------------------------------------------------------------...---- Date PermitNo.............................•........................... Issued_...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................................................................................. Trrtif iratr of ( omplianrr THIS IS T CERTIFY, That Indi 'dual ewag D °saI Syst con0mcted ( ) or Repaired ( ) by...................., -------/ ••--•--•------ __--•- -' ---------•-- i Installer at............................................--•••....•- -- ......................... --•-•-••----------••••--•--••••-•-----•---•-••-•-•--••-•--•---•••-•••••-•••••••-•-••---••••-••-•-•••••- has been installed in accordance with the provisions of Ti 'i 5 o `�he State Sanitary Code as described in the application for Disposal Works Construction Permit No..__.�y_ �/.J._.___.. dated....... ........................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... AL ...... ...... _�_ _':_ ......... ---•---• . Inspector.... n THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 91je � ......................................OF..................................................................................... No......................... FEE._:r..__.........---- Rapi u l u u rnr#imrn Anti Permissio2 ,_Whereby granted----------------------•••--•••--_... _.....-•-• •-•-•••---••-•••--••••-••--••---•---•••---••••••-•••--•--••._...••••-••........__•-••...... to ConstruGt.,P.,,.) o; epair ( n In ividual+ewa , isposal System atNo. .........-1/----.�------------------------------- 1'' ................................................ Street as shown on the application for Disposal Works Construction Pe it No..................... Dated........................................... � I � .......................................... Board of Health DATE --- FORA 1255 HOBBS & WARREN. INC.. PUBLISHERS .a t EEr I of 2SITE PLAN sH SCALE: /��= col s i P o G? 0 12 0 tl� ti `STD• I'I��[s.�T col_.lL� OrA / 4 hrD. t'rzrc4.e.h-r Go1'-14, TA ti D N.djS;- iti� 4D 6 Gz/ 5i , A'k YVARWICK i o \ 1 � No. 19771 ij REGISTERED LAND SURVEYOR l?u-LI- ZONE �G r��"j�f✓�ZV l LL.f-, ( Nl Aug, PLAN REF. DATE BENCH MARK DATUM shy U 0M. M.. WARWICK 8 ASSOC., INC. DOMESTIC WATER •SOURCE '1'n�� wA`��R.. BOX ' 80I - " NORTH FA L MOUTH I FLOOD ZONE. N°�" I-1/a.ZA�-� vim,, MASS. 02536. - (6/7� 563 -26 38 LEACHING J, Si N SECTION NOT TO SCALE Shc•c v/ z Q f Z r 24"C.I.MN COVER f EAkTN\FIL L BRICK AND MORTAR COORSES AS RE0'0• TO BRING �—.., '. COVER TO GRADE 6 I—LOW LINE 2'=y"TO�" WASHED PEA SrONE FREE AF IRONS, FINES AND DUST /N PLACE 1 •', �— '4" rO /k2*WASNEO CR41SHEO STONE FREE OF OPENING W/TH 44" IRONS, FINES AND /X/Sr /N PLACE I OUTER 0/AMETER ANO 1314" INS/DE DIAMErER I. CONCRETE TO BE 4000 PSI 28 DAYS r 2. REINFORCED WITH 6"x6° NO. 6 GA. W.W.M. 3. 2'AND 41 SECTfONS ARE AVAILABLE FOR X GREATER DEPTH REQUIREMENTS 1 �- - }. 6,0" --I 4. NUMBER OF PITS REQUIRED eO MIN/ I 12 — EFFECTIVE DIAMETER -'1 NOTE: EXCAVATE TO ELEVATION 32 OR (NOT ro EXCEED 3 7lMEs EFFECr/VE DEPrH) LOWER AS REQUIRED TO REMOVE ALL WATER TABLE - LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TYP/CAL PROF/LE GRAVEL TO DESIGNED GRADE. i L•151 'Ah4 p! /B"STD. 4r. WGL C.I.MN COVER 4"C.LPIPE 4'B/r.FIBER PIPE OUTLET LEVEL DWELL/NG T/GHl JOINT FLOW LINE 70 FIRST JOINT `�1•�� . TEE /4" 1 10 j 0 o 1 1 I II goo 00 11 11 �•O �p, p 'STD. PRECAST CONC. : �}0.9Jy /STD. O_X r0 BE I 1 O 0O O 0 1 I I 1 . 14000AL.SEPTIC TAN INS ALT LED ON LEVEL, 1 :1 4 0 0 00 01 1 1 STABLE BASE 1 1 f /0 0 0 0 ,1 1 . . ... �_ 111 000 O O 1 1 1 sr/c�iANK TO BE 11 1 0 o o 0 0 1 1 , INSr747LEVFL, 1 it 100100 1 1.1 . STABLE BASE. 1 1 1 0 0 0 0 0 1 1 1: I 111100 0011 , , LEACH/NG BASIN 1 1 1 1 p 0 0 0 0 1 1 , - BASE rO BE L EVEL 1 o 1 o O 0 0 SOIL AND PERC. DATA PERC. RATE MIN. /IN. u TEST PIT NO. I oTEST PIT NO. 2 o TEST BY : ?/Izu r HOL,V WITNESSED. BY �1 fJt; 4At`!p TEST PIT GR. EL. g� 'o DATE: ) 2,( Y� lZ Np CwRw1v.WAT& � . DESIGN DATA GENERAL NOTES BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL r;7otiJ SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL. fGPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK Ioao GAL. ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREAZ'* GAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA I'� GAL./SQ,FT. SANITARY SEWAGE EFFECTIVE ON JULY 11 1977. LEACHING REQUIREDA2 SQ.FT.. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING AREA OF HEALTH. 2 Q.FT. AT -COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES 1/4 / FT. UNLESS INDICATED OTHERWISE. SEWAW DISPOSAL SYSTEM MARTIN �, L $J?✓ L l..cJ S E. 13 MORAN H � LO'� t� opj w�-11TL` Gt -Gl J23411 t? t L L'V- R ��AL A/� �► �j Li F G SS`QIJAL E� ( �� SCALE .AS 1#01GATED DATE I i WM Af WARWICK 8 ASSOC., INC. ®OxW _ :.NORrH fAt hfOUrH 6 I MASS 04?556 - !f/TJ 35.E-2658 PROFESSIONAL ENGINEER No............V..`y�� v Fis.......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH (94Jh>..................OF...........ILIP'2 .`�� ':�'��-':�_r............. -. 12� Appfiratiou for Disposal Works Tatuitrur#inn rumit Application is hereby made for a Permit to Construct (v ) or Repair ( ) an Individual Sewage Disposal System at: ..................................•-------......-- Location-Address or Lot No. 1!%Eor .Ir�. LLoJ ��r S.°1_...... L1.�17......... - A►ik!1 4 ___ ............ ................... j . w O r _ .� dd ess a ��- °- ` _�_.r._ 14 ._..f .iT ..G ...t .s Installer Address QType of Building Size Lot----J_�2t_2 3��Sq. feet Dwelling—No. of Bedrooms._•____________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons_______________.____________ Showers ( ) — Cafeteria ( ) dOther fi�tures _________________________________________•-••-••••-_._._.•-----_____..._---___.__.____.--__..__.____:_____-••-•-•--_______.______...._._..__......____ W Design Flow____.___._5`?_..........................gallons per person per day. Total daily flow................. ...............gallons. WSeptic Tank—Liquid capacity_.`,M/D__gallons Length. P_. Width................ Diameter_______::_______ Depth................ Disposal Trench—No_ ____________________ Width..................... Total Length............___.--- Total leaching area....................sq. ft. Seepage Pit No---------I........... Diameter.........J.a.... Depth below inlet.......✓_____.... Total leaching area��4�!7�sq. ft. Z Other Distribution box (- ) Dosing tank ( ) ~' Percolation Test Results Performed by-_I.A-A-tZs 41_GY.__.. ._9G.................. Date___.__ .'_ Test Pit No. 1....y_.....minutes per inch Depth of Test Pit....19............ Depth to ground water_lJ D_1411L�77. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------------•----______._._._____----__.______________. _____.___--------.................................................... O Description of Soil-••-•••-•••-•c>•n-7-.......... � J V ---------------•-----------------------------------------------------•---------•-----------------------------____----------------------------------- 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 TITLE 5 of the State Sanitary Code—The un si e further agrees not to place the ystem ' operation until a Certificate of Compliance has be ed y o d health. ,r Signed------- •--- ••--- ------ - --------•--••-----•-------------- Application Approved BY ----•- ---- _____ _ -••-----•-•_----- . :� �. ---------------------------------- Date Application Disapproved for the following reasons:-----•-•••••---•----•-•-------••----••-•------•-............................................................... ..............•-•-------••---••••--•-•--•-•--••••---••••-----•-•-•-••••••--••-••-•-----•-----•--•-•--•---._...----------••--------•••----••••-----•----•--------••--••••••-----•-----___.•-•-•-•••-•----- Date PermitNo......................................................... Issued....................................................... Date QQ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'ti.. ........... ... o�......... ........ ` !..... .�� ..............------......--------- Appliration for Dispoiial 3 orkii Tumtrnrtion Vamit Application is hereby made for a Permit to Construct (`/) or Repair ( ) an Individual Sewage Disposal System at: �iG�--•14 - L:.�J c.�s-1 ►i G 112..c t, La�7"�t�dl t�L Location-Address L- ��U LL-6 L-w� �1 iz-, `�JZ H�/� 1J N 10 � t No. :.... ................ - ... ..................•-••---•..._--•-•-••-•.•_.... _.._................••---.................... Owner Address W Installer Address �' Z Type of Building Size Lot._ ..........Sq. feet DwellingNo. of Bedrooms............................................Ex ansion Attic Showers Garba e Grinder ( ) Other—Type of Building ........................... No. of persons............................ ( ) Cafeteria —1P ) g ( ) d Other fytitures . W Design Flow..........7 ............................gallons per person per day. Total daily flow-------------- �J � -------- WSeptic Tank—Liquid capacity_!ACo.gallons Length- ... Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length......._._..,___..._ Total leaching area....................sq. ft. Seepage Pit No-------- ------- Diameter........1_!?_..... Depth below inlet................ Total leaching areal�7'7.0..sq. ft. z Other Distribution box (1) Dosing tank ( ) W Percolation Test Resul�,s Performed bY----...................-- -------•---------------- Date--------................................ N4 Test Pit No. 1____•___--_--._minutes per inch Depth of Test Pit...1 _______.... Depth to ground water! O_«��_. LZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of SoiI-----------` P,l �-'G--C)) l �a...............................................r r x ---------------•-- W —Answer when applicable______________________________________•------______-__--__---___--_-----------------__-..-.-__. U Nature of Repairs or Alterations -----------------------------•------------------•--------------------------------...•••........_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with !"1 T�^ the provisions of :.: T 1._ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed•.---- ............. _..- " -------------••-•---- •-•-••-•-•-- •�••�•a•B`� Date ApplicationApproved BY......................- •----••................................ ----•------- ---------------------------------------- Date Application Disapproved for the following reasons----------------------------•--------•-------------------------...------------------------------••-----•••••..... --------------------------------------------•------•------------------------------------•---------------.--•--•--••-•-•-••-•-•--•----•--••------••--------•••---•------•-------••-•--••---•••----------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS • 3� BOARD OF HEALTH ....................................I.....OF..................................................................................... e 01rdifiratr of Tontplinurr s. THIS IS T6 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ;.--...--•---•---•-.......••-•.....__...--•--•-••••••......_..--•----•-••------••..................... Installer ` ..............................•---------•------ has been i ��p`ordance h the provisions of T ~'e j o The State Sanitary Code as described in the application for Dispos`a� Works LRff9t0�ctior 'e mjt ,N ... dated-.----_----.----_----------------------------- A:--------------- ` THE ISSUANCE OF THIS CERTIFICATE SMALL NOT 1 CO6dSTRUED AS A GUARANTEE.THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ....f ----v..-.G:'.0.." , 11�1...... Inspector = DATE............: r` j` THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH ...........................................OF....................................-.........:...................................... , No......................... FEE........................ Permissionis hereby granted..........................................................................................................S^ ............................. to Construct ( ) or Repair ( - I ividual Sewage Disposal System atNo. ...........................--•-- ---•----••---•--•--••-••---•••-----••••---•--•----••-•--......-----••-••--...••......... Street as sh n-i4pplicatio o ispo r onstruction Permi, No...................... Dated.......................................... M._ 1 Board of Health DATE-------------- ----------------•---------•-•-••-----------•-••-••-•-----•••••-- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - SITE PLAN . sHeEr I of 2 SCALE: / . h T R rV-S e a.gT e,,v"6 Iv00 61A1_ rzFT1G Th,^,4V— z- !�" j' N. , �Q p_ �` x <A R liz, N_Q L7 O t I ......�,0 I 1 L I i I OF b I s J 1 ' I 1 1 I D � � 1 ' Zn.11 e C' WILLIAh1 M. ��.,� h �Zo �71 I.$u v-J cza c� WARWICK v i NO. 19771 S,�lq��ISTEQ�D s` G 1 i�G �r; % U I ri V , L,144,4 FOR REGISTERED LAND SURVEYOR I re ZONE tr—ytL.L- ►'AA-�� PLAN REF. /� /<7, J�. ?'�M �_ �.._ DATE BENCH MARK DATUM WM. M. WARWICK 8 ASSOC., INC. DOMESTIC WATER ,SOURCE 80X SO/ — NORTH FALMOUTN FLOOD ZONE. �'�"� �`Z' �' nGu MASS. 02536 - (6/7) 565 —2636 �. LEACHING BASIN ,SECTION NOT TO SCALE She'e l 'e f Z' ` 24 C.[MH COVER EARTH FILL BRICK AND MORTAR COURSES AS REO'D• TO BRING 4: ,T.�_ µ _ COVER TO GRADE,„ INLET �B FLOW LINE _._:,j y. 2"_ "TO WASHED PEAS TONE FREE OF IRONS, PIPE T FINES AND DUST IN PLACE OPENING WITH 4% �4 TO I k,?"WASHED CRUSHED STONE FREE OF 71 OUTER DIAMETER„ IRONS, FINS AND DUST /N PLACE AND /-3/4„ INS/DE DIAMETER I. CONCRETE TO BE 4000 PSI 28 DAYS .•' f ; ' 2. REINFORCED WITH 6%6" NO. 6 GA. W.W.M. • 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR GREATER DEPTH REQUIREMENTS 40" r--2 —�--s 0" 1-2' —� 4. NUMBER OF PITS REQUIRED MIN. l 1z EFFECTIVE DIAMETER NOTE: EXCAVATE TO ELEVATION Z OR - - Ivor ro ExcEEo 3 r/MEs EFFECTIVE DEPTH! LOWER AS REQUIRED TO REMOVE ALL • WATER TABLE - LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TYPICAL PROF/LE GRAVEL TO DESIGNED GRADE. L' C-L Aq.p /B STD. LT. WGT. C./.MH COVER 4"B/T.FIBER P/P£ 4"C.I.PIPE _„ T/GNT JOINT OUTLET LEVEL DWELLING FLOW LINE 0 TO FIRST JOINT 00 1 10 00 1 0 C.I. TEE 3�,o �a•7�i i it 0 0 0 00 1 1 I i Z� y � .'STD, PRECAST CONC. �>3.�f DIST BOX To BE �J$•�o ' ' f 0 00 00 1 1 000GAL.SEPTIC TAN INSTALLED ON LEVEL f 000 00 0 1 I I . STABLE BASE ' '1 000 00 0,1 --.. � if000 0001 . � ASEPTIC TANK To BE '1 0 0 0 00 D 1 I INS T L�LEVEL I L00�0 a ! 1 STABLE BASE. i ' 1 0 0 0 0 0 i100010 0 1 1 , LEACHING BASIN i f B 010 , OD D BASE TO BE LEVEL i 180 0 ► 1 , , !✓I.CV �a•5 SOIL AND PERC. DATA PERC. RATE : ` MIN. /IN. o„ TEST PIT NO. 0� TEST PIT NO. 2 TEST BY PtzuGGu>7 WITNESSED BY: IZoi.J 6.t.F-paEp 0 vlr+-' Mo V1Lim t�_jv TEST PIT GR. EL. �'I • v 5 �� DATE: IJa G.R�.1D.wATE� DESIGN DATA GENERAL NOTES BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL.22"O' PRECAST REINFORCED CONCRETE UNITS. GPD. SEPTIC TANK to°G GAL. ALL SYSTEM COMPONENTS SHALL BE INSTALLED, IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREA �'� GAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA La' GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY Is 1977. LEACHING REQUIRED1"`1 SD.FT. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING AREA OF HEALTH. ��0 SQ.FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES I/q / FT. UNLESS INDICATED OTHERWISE. OF SEWAGE DISPOSAL SYSTEM � MARTIN E. v MORAN• H y23417��Q LOT I[9 1�jO if3 L,tJ L T G l ;✓G L. '-V►1.t- A4 FSS`ONA SCALE AS IND/CArED oArE k • WM. M. WARWICK 8 ASSOC.,.I NC. BOX 80/ - NORTH FAL MOUTN )214; ` MASS. 025 5 - <61N 56.3 -26:8 PROFESSIONAL ENGINEER