Loading...
HomeMy WebLinkAbout0046 BRIAR PATCH ROAD - Health e-�W<l i o � 4 Commonwealth of Massachusetts "�✓� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 BOBWHITE CIRCLE c Property Address BROWN - Owner Owners Name information is O requiredSTERVILLE V MA 7-15-16 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 r way.Please see completeness checklist at the end of the form: Important: A. General Information When filling out (Sl forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. !BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 t�L - 7-15716 Inspector's.0ignature 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. 1f 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. :f t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 1 of 17 �U Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 BOBWHITE CIRCLE Property Address BROWN Owner Owners Name - information is required for OSTERVILLE MA 7-15-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or /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: - SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no or"not determined"(Y, N,ND)for the following statements.if"not determined," please explain. The septic tank is metal and over 20 years old"or 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: i *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•3/73 Title 5 Official_Inspection Form:Subsurface Sewage Disposal System•Page 2 of"17 Commonwealth of Massachusetts For m �ICI�I Inspection Title 5 � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 every page. Cityrrown State Zip code Date of Inspection B. Certification (cont.) ❑ Pomp 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): ❑j 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.3113 Title 5 Ofridal Inspection Form:SubsurraceSewage Disposal System•Page of 17 t Commonwealth of Massachusetts Title 5 Offici al Inspection 101 Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 25 BOBWHITE CIRCLE ProPerty Address BROWN Owner Owner's Name information is MA 7-15-16 required for OSTERVILLE every page. Cityrrown State Zip Code Date of.lnspedion 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.hais 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: I 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 El 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 l ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less. than day flow Title Official Inspection Form:Subsurface:Sewage Disposal system:Page 4 of 17 t i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. ,..'' 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ . ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS;cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or El ® tributary to a surface water supply: ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well j❑ ® Any portion of a cesspool or privy is within 50 feet of a privatevater 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 El 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 El ❑ the system is within 400 feet of a surface drinking water supply El ❑ 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 at significant threat under Section E or failed under Section D shall upgrade the, system in accordance with 310 GMR 16.304. The system owner should contact the appropriate regional office of the Department. 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Dispose)System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s•. 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 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 El this inspection? Were as built plans of the system obtained and examined?(If they were not 0 El available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of breakout? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction; dimensions,depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with 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: R ❑ - Existing information. For example,a plan at the Board of Health. �' ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM.R 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: 11 G gpd x#of bedrooms) 330 15ins•3113 - Tile 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 '< 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO PERMIT SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK D-BOX AND 2 500 GALLON CHAMBERS WITH 4 FT OF STONE IN A 25X13X2 FT AREA Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No. Is laundry on a separate sewage system?(Include laundry system inspectionEl Yes ❑ No information in this report.) Laundry system.inspected? El Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: SYSTEM NOT DESIGNED FOR GARBAGE GRINDER AVERAGE GPD FOR 20.14-=-203 2015--197 Sum pump?P P P El Yes ❑ No Last date of`occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): canons 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?` El Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7.of 17 I Commonwealth of Massachusetts Title 5 Official .Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's(Name information is required for OSTERVILLE MA 7-15-16 every page. Cityrrowrl State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source.of information: Was system pumped as part of the inspection? ❑ yes ® No If yes, volume pumped; gallons How was quantity pumped determined? Reason for pumping_ Type of System- Septic tank, distribution box, soil absorption'system El Single cesspool El Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner),and a copy of latest inspection of.the I/A system by system operator under contract ❑ Tight:tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official-Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 BOBWHITE CIRCLE Property Address BROWN Owner Owners Name information is OSTERVILLE MA 7-15-16 required for 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: S.A.S INSTALLED IN 2001 ACCORDING TO PERMIT Were Sewage Odors detected When arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑other(explain) Distance from private water supply well.or suction line: feet Comments (on condition of joints, venting,evidence of leakage, etc.): Septic.Tank(locate on site plan): Depth below grade: 2 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: Sludge depth: t5ins•3113 - :Title 5 Official Inspection Form:Subsurface Sewage Disposal'System•Page of'17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 25 BOBWHITE CIRCLE Property Address BROWN Owner owner's Name information is required for OSTERVILLE MA 7=15-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont;) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of Leakage, etc.): RECOMMEND PUMPING AT TIME OF TRANSFER AND EVERY 2-3 YRS THERE AFTER. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑;.metal ❑fiberglass ❑ polyethylene ❑ other(explain) Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins 3/.t3 - - - Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10.of 17- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 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: Material of construction: ❑concrete :❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level Alarm in working order: ❑ .Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.)` Attach copy of current,pumping contract(required). is copy attached? ❑ Yes ❑ No t5ins•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 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 every page. Cityfrown State Zip Code Date of Inspection D. System Information (coot:) Distribution Box(if present most be.opened)(locate on site plan): 0It Depth of liquid level above outlet invert Comments.(note if box is level and distribution to outlets equal,..any evidence of solids carryover;any evidence of leakage into or out of box,etc.): BOX LEVEL NO LEAKAGE OR SOLID CARRY OVER. Pump Chamber(locate.on site.plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass: Soil Absorption System (SAS) (locate on:site plan, excavation not required): If SAS not located, explain why: COULD NOT LOCATE VIEWED THROUGH VENT PIPE t5ins•.3113 - Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 12 of17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w a 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 every page. Citylrown State Zip Code bate of Inspection D. System Information (cone.) Type: El leaching pits nu mber: leaching chambers number: 2 per permit ❑ leaching galleries number: - leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,.damp soil, condition of vegetation, etc.): AT TIME OF INSPECTION THERE WERE NO SIGNS OF FAILURE: Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth!—top of liquid to inlet invert Depth of solids layer Depth of scum layer. Dimensions of cesspool Materials of construction f Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System'Page.13 of 17 Commonwealth of Massachusetts - u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction; Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,:condition of vegetation, etc.): t5ins•3113 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System!Page 14 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not forVoluntary Assessments 25 BOBWHITE CIRCLE - Property Address BROWN Owner Owner's:Name information is required for OSTERVILLE MA 7-15-16 every page. Citylrown 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 t5ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 15 of 17- - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 BOBWHITE CIRCLE Property Address BROWN Owner Owner's Name information is required for OSTERVILLE MA 7-15-16 every page. Citylrown State Zip code Date of inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: NONE ENCOUNTERED 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:. ATTACHED 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` Before filing this Inspection Report, please see Report Completeness Checklist on next page.; l5ins 3113 Title 5 Official Inspection Fonn: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 v 25 BOBWHITE CIRCLE Property Address BROWN Owner Owners Name information is required for OSTERVILLE MA 7-15A6 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary:A, B. C, D,:or E checked ® Inspection Summary D(System Failure Criteria Applicable to All:Systems)completed ® System Information—Estimated depth to high groundwater. ® Sketch of-Sewage Disposal System either drawn on page 15 or attached in separate:file { t5ins•3113. ._ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 17 of 17 Fee 5 0...✓ THE COMMONWEALTH OF MASSACHUSETTS Fettered in computer Yes PUBLIC HEALTH DIVISION•TOWN OF BARNSTABLEs MASSACHUSETTS Zippitcattton for 13topozdi Opotem Conotruction Permit } Application for a.Permit to Construct( )Repair(X )Upgrade( )Abandon{ ) O Complete System O Individual Compona= i Location Address or Lot No. Owner's Name.Address and Tel.No. 25 Bob White Circle,, Maureen Downey Assessor's Map/Parcel O s t ery i 1,l e,; MA Installer' Name-Add=,[tl e.No. Designer's.Name,Address and Tel.No. �Wm. E. Robinson Septic Ser� P. O Box 1089, Centerville''' Type of BuildiLg: Dwelling moo.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 J Title Size of Septic Tank Type of S.A.S. Description of Soil Sand E i i Nature of Repairs or Alterations(Answer.when applicable)_ Title-5 I ea n h system r nn G G t i n 9 j of a d-box and 2 precast leach chamber with. stone all around. Date last inspected: I Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title S of the Environmental Code and not to place the system in operation until a Certifi; cate of Compliance has been issued by P Bo of Heal . Signed Date 3 Application Approved by Date.3—Z?--G Application Disapproved for the following reason s Permit No, Date Issued --- ———— -- -- ——- ---.-- . — — -- { I _ r i i i. l •\' aYX 3 s hi'a1- r ! -TOWN OF BARNSTABLE �" l... LOCATION l 1 SEWAGE # �' / VILLAGE OS'' 2:1( F. ASSESSOR'S MAP &LOTS 4' 'a 3 O INSTALLER'S NAME.&PHONE NO. S- T I? f—\ SEPTIC TANK CAPACITY J LEACHING FACILITY: (type) 7P_u cn)et S .(size) lc ?"ay `0 L NO.OF BEDROOMS BL71LDER 0,R O PERMITDATE: /2 7 COMPLIANCE DATE: S�3I�c�e i . Separation Distance.Between the: t Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well 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.ezist within 300 feet of leaching facility) Feet - Furnished by 6. r Back Pear f" ` a f Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address: 25 Bob White Circle Osteiville.JvM. Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27.2005 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. E 3 5�now�� 1-1c) 0� f a 3 ;0-1- ;LO� - y135' Ys 10 - - _ -_- i EFrEf ,iYE ola; Tr r'lvoT T �Y r E it r cFEo ;,r-�E- ;iFEcr,.� oFPTH;1 1�1- AND l('10 HEAVY EQUIPNI TEi7 SEPTIC TANK C=iST� t t?t --- -----•---- �..-------- PRECAST ' - ,• REIMF ALL SYSTEM comp 7 ?�; TO REVISED Tf �} r;• p ,.10 i -~ tMIMI'MUM R>;i? 5T t11.R I __ SA?.IITAR ,E°r�Q f ! I HOARD j OF HEAL: AT COMPLETIo,\i BOARD OF HEAL PITCH ALL SIvyu; I, OTHERWISE. { - —_ J.0�I Sr - F'OSALES: T `.'AL F F. J�flt_ ;> —GALS. SEP;'IL SOTTQ%-j ;aREA G�1L./SQ. FT { ---- GAL./So, FT- °.LEACHIN0 FtE�JUIR•EO 1`�:fi. at SO.FT. C' +t TJAL LtAC1 1NG A;IREA-,�o-I;�g:SO:FT S1 ►ili,`{ SCALE p l t w4f. BOX. L COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIONS —4 Cj i 1 d.r .v 21 !, t1 i TITLES U; OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE.DISPOSAL SYSTEM FO" S PART A �- CERTIFICATION Property Address: 25 Bob White Circle Osterville. MA 02655 Owner's Name: Bob&Rhonda Gracilieri Owner's Address: 35 Riverside Drive `Ia9 Reading. MA 01867 Date of Inspection: September 27, 2005 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and 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 Needs urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: October 3,2005 The system inspector.shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Bob White Circle Osterville, MA Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Bob White Circle Osterville. MA Owner: Bob&Rhonda Gracilieri Date of Inspection:' September 27, 2005 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. I. 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. 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Bob White Circle Osterville. MA Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 du e to an overloa ded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped—. _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Bob White Circle Osterville. MA Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27 2005 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: Yes No ✓ — Existing information. For example,a plan at the Board of Health. ✓ _ Detennined 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Bob White Circle _ Osterville. MA Owner: Bob&Rhonda Gracilieri Date of Inspection: Sevteniber 27 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ------gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 513101 ver as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob White Circle Osterville AM Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27 2005 BUILDING SEWER(locate on site plan) , Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" 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: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Cement tees were resent. The liquid level was even with the outlet invert. There didnotyppearto bean siznsofleakaize. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping reconunendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBS URFACE SEWAGE DISPO SAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob White Circle Osterville MA Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27 2005 TIGHT or HOLDING TANK: None (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: allons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were Present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 y Page 9 of 11 _ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob White Circle Osterville, MA Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 drvwells- 12'x 2'x 30'(per as built card) 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.): The d.rywells were dry and clean. There did not appear to be any signs.offailure. The bottom to grade was 6. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Continents (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.):, 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob White Circle " Osterville MA Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27 2005 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. C snow" 'Q ow(3�Gk 3r-411 A. 6 3 a y 3S ys 10 f Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob White Circle Osterville MA Owner: Bob&Rhonda Gracilieri Date of Inspection: September 27 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground wa ter eleva tion: Using Barnstable topographic and water contours maps the maps were showing approximately 30'+/ to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 y TOWN OF BARNSTABLE r LOCATION C� i3ob C SEWAGE # O'� �d 3 III AGE 0 STe rot l fit. ASSESSOR'S MAP & LOT N 3- U 3 0 iNSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY QUO LEACHING FACILITY: (type) � I S (size) Q x 3 o x a NO.OF BEDROOMS / BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: 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 leac ng facility) Feet Furnished by Fo/� C A' of O y � 3S YS TOWN OF BARNSTABLE LOCATION t(Zr- 1 E— SEWAGE # Z" /-J 9'3 VILLAGE (�)--S+V=20 ASSESSOR'S MAP&LOT/Y�"03 o INSTALLER'S NAME&PHONE NO. i"LDS aQ 53 Tc�Z ?7 S'- B Z?(o SEPTIC TANK CAPACITY d� LEACHING FACIL=: (type) _ DP-V tNC-k(S (size) lo-?71,o`l-i ?O t NO.OF BEDROOMS BUILDER O OWNE PERMIT DATE: -7 /adcj 1 COMPLIANCE DATE: o® f 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 O - y T ✓ J er�: Ff;1, Fee 5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplitation for Miocoal *patent Con5truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 25 Bob White Circle, Maureen Downey Assessor's Map/Parcel O s t e r v i l l e, MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Ser P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 1 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 s a n rl Nature of Repairs or Alterations(Answer when applicable) Title-5 1•each system consisting— of a d—box and 2 precast leach chamber with stone all a round. �-- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal.system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi= cate of Compliance has been issued by thi Bo of Healt . Signed L Date Application Approved by Date '3' 22-7-o Application Disapproved for the following reason Permit No. r_3 Date Issued --------------------------------------- No-- . Fee` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS tt j—O Z(pprtcation for Wgpogal .pgtem"Congtructton Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor'sr3� ip&gb_White Circle, Maureen Downey Osterville MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. .Robinson Septic Ser P 0 Box 1089 Centerville , Type of Building: Dwelling No.of Bedrooms'_ Lot Size sq. ft. Garbage Grinder( ) Otber Type of Building No. of Persons Showers( ) Cafeteria( ) Othei Fixtures Design Flow gallons per day. Calculated daily flow gallons. b Plan Date Number of sheets Revision Date Title Size of Septic Tank pe of S.A.S. � s Description of Soil ! i Sand Nature of Repairs or Alterations(Answer when appfi le) Tit i e - `` i4 QL arounr7. : 1 -� f— � t Date last insp c ed'"=-�-- ------- Agreement: "--The undersigned ag-rees.to.ensure ttie construction and"m fintenance of the afore described on-site sewage disposal system in accordance with the provisions of Tifl'e 5 of the Environme tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo of He la h i ` .` Signed Date "U Application Approved by Date Application Disapproved for the followng,re�n` Permit No. Date I`hued p THE COMMONWEALTH OFIMASSACHUSETTS BARNSTABLE, MASSACHUSETTS of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(`X )Upgraded( ) Abandoned( )by Wm E. Robinson Se�_o i Sery)bkee at- 25 , _ . i to a has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 744 11 dated_ 91dw T—7 2-U/. Installer ram E, I o ;n csan S;;,- Designer The issuance of this ermit shall not be construed as a guarantee that the syste wit function as d6signed. Date Inspector 7y / 1 No. 1— /�a `t' Fee $ n THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS I gpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( X)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 ofXhienit. Date: 1/2:7 o i Approved by - e - NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKLICH AND APPLICATION FOR A DISp'OSAL WORKS CONSTRUCTION PERMff(WITHOUT DESIGNED PIANS) son Willi:atn E Robin S �, y certify that the appLcanon i..r disposal works construction permit sped by ate dated w concerning the praPerty located at 25 Bob.-White Circle, Ostervilletneetsallofthe following caitetia • The failed system is amnectod to a residea[ial dwelling only..There are no coca neiciat or business asses associated with dwelling. i The soil is as CLASS 1 and the peroolatimn tee a less Wan.0 aquml to 5 mimues per inch There are tW within lOq feet of the piOp06Ol19Cp11C stistem _ There arc:no p wells within 150 ieet of the proposed septic S3-AMI There is no i in flaw aadlor a is use pmpmd • There are varisnaes req�tM neoded • The of the ptopoaerl Ong facility►will Abe located less than'fives foes above the ma+tittrum wed groundwater table elevation:[Adjust the groundwater table using the Frimptor method when applicable - if the SA-S.will W lasted with M feet of my;vegmwd wetlands.the boaoin of the proposed leaching,Wft will_t be located less than fourteen(ld)feet above the mam utm adjusted groitndtvater table eletratiort, Please eouplae the fiillawraag A) Top of Ground Sutfaoe Fkvazion(using GIS iuhwation) , Eli G.W.Ekvation +the MAX. High G.w. t DIFFERENCE BETWEEN A and B slcrlEn: DATE- —L7- (Sketch proposed plan of sysem on ba*1. Ir beam f ow.A-en i TOWN OF BARNSTABLE LOCATION --t.\ l(2c SEWAGE # �' VUILAGE- Os-�E(Z ASSESSOR'S MAP & LOT/ -c3 o INSTALLER'S NAME&PHONE NO. 5` SEPTIC TANK CAPACITY LEACHING FACILITY: (type)- 172V cA,)Q- S (size) lo-? `NCO _ L NO. OF BEDROOMS BUILDER O. .O 6`L �. . PERMIT DATE: {-D-7 /a t COMPLIANCE DATE: 5/3 X 2" 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) Feef.. Edge of Wetland and Leaching Facility (Lf any wetlands.ezist wi in feet ofleachin facili Feet tlu 300 g tY) .. i Furnished by r { t fix,,. - - Back- 0 a c� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR TEP 1/1= _D �•' MAY 2 9 2001 TUVvI,,ur 8ARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Bob—White Circle Osteryil_le' MA Owner's Name: Steve 9 Maureen Downey Owner's Address: same Date of Inspection: Name of Inspector: (please print) Wi I 1 i am E_ .Robinson sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5 0 8) 7 7 5—8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and 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 S on 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspectors Signature: w Date: h The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh''or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments , ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). PropertyAddres's= 25 Bob—White Circle `Osterville Owner: Date of Inspection: F> Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m 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: System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repa ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answ ryes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla' . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsou id,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existiz g tank is replaced with a complying septic tank as approved by the Board of Health. •A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ting that the tank is less than 20 years old is available. ND xplain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND ex lain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass ' spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed D explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:25 Bob—White Circle Osterville Owner: Do. Date of Inspection:Y- /—D 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 fail' to protect public health,safety or the environment.. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s stem 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 . P or �'Y Cesspool or-privy is within 50 feet of a bordering vegetated wetland or a salt marsh P 2. Sy tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 rface 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 front a pr vate water supply well**.Method used to determine distance ** his system passes if the well water analysis,performed at a DEP certified laboratory,for coliform ba teria and volatile organic compounds indicates that the well is free from pollution from that facility and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm;provided that no other f ilure criteria are triggered.A copy of the analysis must be attached to this form. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Bob—White Circle 1e Owner: Dnwne�� Date of Inspection: >=L D. System Failure Criteria applicable to all systems: u must indicate"yes"or"no"to each of the following for all inspections: Ye No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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. L rge 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. You ust indicate either"yes"or"no"to each of the following: (The ollowing criteria apply to large systems in addition to the criteria above) 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 yo 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 sig ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 04.The system owner should contact the appropriate regional office of the Department. 4 ,r Page 5 of II OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Bob—White Circle pctorvillA Owner: DONnpv Date of Inspection:T Check if the following have been done You must indicate"yes"or"no"as to each of the following: i/—o 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) I Was the facility or dwelling inspected for signs of sewage back up ? 7/ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site t/ 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: Yes/no C� 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Bob—White Circle ncztarvil � A Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):C Number of current residents: Does residence have a garbage grmder(yes or no): Is laundry on a separate sewage system(yes or no)/2.4 [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):A0 Water meter readings,if available(last 2 years usage(gpd)): 2000 1030000 gal. Sump pump(yes or no): 2 1999 108, 000 gal. Last date of occupancy: C MMERCIAIANDUSTRIAL T of establishment: Desi n flow(based on 310 CMR 15.203): gpd Basi of design flow(seats/persons/sgft,etc.): Gre a trap present(yes or no): Indu trial waste holding tank present(yes or no): Non sanitary waste discharged to the Title 5 system(yes or no):_ Wa er meter readings,if available: L date of occupancy/use: HER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How w quantity pu iped determined? Reason for pumping: �;a A =sa,. I�%n,1 �, f w S>p J. TYE 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): 3 6 Z Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no) 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob—Wh; tP Circle Osterville Owner: D Date of Inspection: +p - -- j ' 4 BU LDING SEWER(locate on site plan) Depth elow grade: Materia s of construction:_cast iron _40 PVC_other(explain): Distanc from private water supply well or suction line: Comme is(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: '-Zate on site plan) A Depth below grade: - Material of construction: (/concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) I ' N Dimensions: / Je Sludge depth: nL Distance from top o sludge to bottom of outlet tee or baffle: 4,,V Scum thickness: O ] ' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of gytlet tee or bale: L How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle.condition,structural integrity,liquid levels as related to outlet invert,evidencyof.leakap,etc.): GR SE TRAP:_(locate on site plan) Depth low grade:_ Materia of construction:_concrete metal_fiberglass_polyethylene_other (expla' Dimens ons: Scum t ickness: Distan a from top of scum to top of outlet tee or baffle: Dista ce from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as elated to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob—White Circle Osterville Owner: Downe . y Date of Inspection: TI HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dept below grade: Materi 1 of construction: concrete metal fiberglass_polyethylene other(explain): Dimens ons: Capaci gallons Design low: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date o last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Xifresent must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUM CHAMBER: (locate on site plan) Pum in working order(yes or no): Al s in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob—White Circle Osterville Owner: Downey Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): Z (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): CL V CESSPOOLS: (cesspool mu be pump art of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet in : Depth of solids layer: V Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PR (locate on site plan) Mate ials of construction: Dim nsions: De h of solids: C ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob—Whitt— circle Osterville 41 , Owner: s;Downey . Date of Inspection: 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. ry J I Y � a 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Bob—White Circle Osterville Owner. Downe Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells l Estimated depth to ground water 6 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mus descri a ow you estab ish d the high ground water5levation: 11 zs- LO CAT lON SEWAGE PERMIT NO. VILLAGE o� R- 143 030 INSTALLER'S NAME & ADDRESS 9 U I L D E R OR OWNER �.I-TS L L 4 t-tl E-Lj? DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 3ZJ-71tX r 10 411t� �r No. 3` 0 y Fss...� .............. ^� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Apptiration for Bhip a al Workii Tomitrurfivat Frrutit Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System at: ..!-° ..a... o_13 ` r► ► � -G-............................... !�5.j (L11�lam,_$ I��T � ._n!1 .:.......-- ocation-Address or Lot No. ------------------------------------ ----------- f ,.a Installer Addr s Type of Building Size Lot... feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building �7�......_..... No. of persons............................ Showers Cafeteria a YP g -��---- P ( ) — ( ) Otherfixtures --------------------------------------------------------------------------------------------------------------------------•--------------•----------- W Design Flow...........1 1~...........................gallons per person per day. Total daily flow...... ____................__gallons. WSeptic Tank—Liquid capacity_IMP..gallons Length.�t7.... Width................ Diameter--------------.. Depth................ x Disposal Trench—No......... ..... Wid .................... Total Length.................... Total leaching area..__........_.._....sq. ft. Seepage Pit No.......)------------- Diameter.__.__.___.__..... Depth below inlet... 7_............ Total leaching area��..S. Jsq. ft. Z Other Distribution box (✓) Dosing tank ( ) '~ Percolation Test Results Performed by._.J0.414_. .�7....................................... Date-----5 07-3�.............. a r7-V17 Test Pit No. 1......z----minutes per inch Depth of Test Pit....12.......... Depth to ground water....N-0-k- . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••••••-•••••------._...•-•••••-•--••••----••-•••••...........••••••-•-•-••--•-•.............................................................................. O Description of Soil..............._' .. ._ ' �� (hl __wN►PAT>✓]7_ �iND W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed'Inividual Sewage Disposal System in accordance with the provisions of TITS 5 of the State Sanitary Code— ndersigned further agrees not to place the s stem i operation until a Certificate of Compliance has b d oard of health. Signed. . .......................••---..............••--- � . . - ApplicationApproved By.................................................................................................... ---------------------------------------- Date — Application Disapproved for the following reasons--------------••-•••-•-••---•••••----••-••-•••--••-••-•••-•----•-----------••••-•••--••• ...................... .........-•-••••-•-•--••-•----••••----•------••-•---•••-•--••.....--•--•••-••-••------•---•-•-••••-•-•------••-•-•-••••••--------•-•----••••----••---••-••••---••---•......-----••-••-------•••••-•----- Date PermitNo......................................................... Issued........................................................ Date t FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............._OF........... ��' Appliration for Eliupuual Worse Tomitruriiott "rrmft Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System at: ... �'."(... 0�._ a ..,,�...►; 1�e'L t; .------. % ........... Location Address or Lot No. W Owner Address ' •...................................••-----•-----------•---•---------............................_ ...... ¢ � Installer Address Q Type of Building Size Lot___- 2�--Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building 12 C'`7 � YP g -,-----�-• --•=--------•-- No. of persons............................ Showers ( ---)--- Cafeteria•(----)- QOther fixtures --------------------------------------- -------------------------------------------------------------- Desi n Flow........... .. ........................gallons per person per day. Total daily flow__---_- ._.___.............W g - g P P P Y Y .� �© ---•----.dons. WSeptic Tank—Liquid capacity__�1e).gallons Length_- I•IZ,__- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width-------------------- Total Length......____...._..... Total leaching area....................sq. ft. Seepage Pit No........I------------ Diameter--_�Z_ .......... Depth below inlet.... •......._... Total leaching area.>:G_!.:�2sq. ft. Z Other Distribution box (✓) Dosing tank ( ) ~' Percolation Test Results Performed by._n_J�.!A.&L_-l✓L.LIB....................................... Date___._G�:.� ............. aPZ 17 Test Pit No. I...... ____minutes per inch Depth of Test Pit----!2........... Depth to ground water--__N_�.!�1. . fq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... P4 --- ------ ----------------------------------------------•-------------............................--•-----...........•--•••-•--•-•-••--............--.••••. O Description of Soil................. ----•----1�= =.........................r ( �` �J - i n,I L. GG'-=V11?A.Ga_t✓ l�!v D V ...............................-•••••--._...•-•-••-•.....•----•-•••-••--••----••••---...••••---•--•••••--------••---------------••......---•--. 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 TITLi: 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...................................................................................... ..........................--.... Date ApplicationApproved By............................................................................................--- Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------ ------------------•--- ------•.........-•-•--••-•-----•-.....•••---•-••••-------•-••...••-••••-•-•--•----•--....•-------•••-•-•--•••-•---------•--------•••----•••-----•--•••••-------•---•-••---------------------------•-•--- - . Date PermitNo......................................................... Issued_..............................-•--••-•••-------•------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... C9rdifiratr of Toutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at......................................................................... has been installed in accordance with the provisions of TITLE: j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated------------.................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT /CONSR AS A GUARANTEE THAT THE SYSTEkI Vyl FU ION SATISlFACTORY. DATE... Inspec THE COMMONWEALTH OF MASSACHUSETTS Q qt� BOARD OF HEALTH .................... 41�,R l f� ..................OF......... --.............................-•--•-................................ No... ....._. FEE........................ Raposal or u �ottu#r iott rrttti# Permission is hereby granted.... ......1-�:/-�11 Al---------------------------------------------•-•-------••------...............• .. to Construct'(�r Repair ( ) an Individual Sewage Disposal System atNo.......k47.....•.....----- #3... ('`1 -/1 ............................................................................................................. Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ...........-•-----------•----•-••---•------••-•--•...-- ---•••--•--------•--•••••••- g Board of Health y DATE :.._ !9 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS S/ TE P-L A A/ T KI DI C, A L P,f?!i t- l SCALE _. , " ., �L �L: '��G. 5 NOT TO SCAr_ t 16"STD. L T WG T C./. MH Co vE.q 5 4"C.l. PIPE 4"BIT, FIBER PIPE TIGHT ,/O/,VrS FLOW LINE OUTLET LEVEL TO FIRST ✓DINT 14 �3 DWELLING 9 Dol /4" 'IT- -- O O O C.l TEE —! STAAIDARQ PRECAST '--� "I`^�O,O ' CONCRETE °ODGALLON �{ ,oP � SEPTIC %ANK I _\ DISTRIBUTION Box B TO BE INS TAL L ED ON LEVEL , STABLE BASE SEPTIC TANK TO BE INS TA L L ED ON . LEVEL , STABLE BASE + r l l 2` - 1/8 TO 1/2" WASHED PEA STONE LEACH/NG P/T 1 ALL AROUND FREE OF IRONS, FINES BASE TO BE LEVEL AND DUST IN PL ACE 'V ��� ! ' BR/C}C B MORTAR COUR£S 'J-- , Iv 57 zg r AS kEQU1RE0 TO BRING 3/4'1 TO 1-1/2 ' WASHED CRUSHED STONE ALL AROUND FREE OF,j i 1 o. <;p COVER TO GRADE 24"C.I. MH COVER IRONS, FINES AND DUST IN PLACE A ND FRA M£ - p. 0-AX I A � y T P. P aUa s7 Gc tiG• 2° 4„ 4 - `-_�' LEACHING PlT SEC T/ON— /NL Et 8 FLOW L 1l'IE _ _ (" o� fl PIPE ( 1 I. CONCRETE TO BE 4000 PSI 28 DAYS 3Z 2. REINFORCED WITH ` 6. x 6 N0. 6 GA. W.W.M 3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREAI•ER ti }� DEPTH REQUIREMENTS. OPENING W/TH 4 //6` ! 4. NUMBER OF PITS REQUIRED � ��__ _ -- 3 OU rER o1AME T£R B NOTE: EXCAVATE TO ELEVATION "2 O 0R LOWER AS m N { I-3/'a INSIDE DIAMETER 3" REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH �P PIT REPLACE EXCAVATED MATERIAL WITH CLEAN GRAVEL TO DESIGNED GRADE ' Sv• m n ® P2v 17 MIN. EFFECTIVE 014MET£R 1 Z '- ,p" (NOT TO EXCEED 3 rIMES EFFECTIVE DEPTH) - - -�---J WATER TABLE -- NC,�r:, A i~ 6 L. •7�j,p1 SO/L AND PERC. DATA GENERAL NOTES PERC. RATE , MIN. /IN , NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. J o0 ►.1 F-LL-!5 SEPTIC TANK, C'ISTRIBUTION BOX , LEACHING PITS TO BE STANDARD TEST P1f: ___ -F-LL-1 PRECAST REINFORCED CONCRETE UNITS ~ W I T N E S ED BY- �_J L'_11 *.! �.1 A l - a � pj , L.� . ALL SYSTEM, COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE , TEST PIT GR EL 3� ' d DATE : S ' 16 'a� MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL DF TEST PIT NO, P Zv1 1 TEST PIT NO 2 SANITARY SEWAGE EFFECTIVE ! JULY 1977. 0 ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE 4c' njho!L. BOARD OF HEALTH AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE 1�►�G~%Iv�YA�T�T� 1 BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. SAND PITCH ALL SEWER LINES 1/4" /FT. UNLESS INDICATED OTHERWISE. Nit IJN D1t.�A f DELIf N DADA BEDROOIS DISPOSAL 0 f•%� EST. T07AL DAILY EFF. GALS. L EGEND "" SEPTIC u►NK lade— GAL SIDEWALK. AREA GAL./SO. FT BOTTOM IREA --I, GAL,/SO. FT 4xD"^ EXISTING GRADE LEACHIN9 REQUIRED ""2'1040 SO FT SEWAGE DISPOSAL SYSTEM ZONE ._ _ oo�} FINISHED GRADE ACTUAL _EACHING AREA --. -'e..-'SZ�SQ.FT. sFOR aJZ DOMESTIC _WATER SOURCEs! \-Q ��„ '� O INVERT ELEVATIONt' " � - -- � - - PLAN REFS 4 I-Pv,;• }� f�. -C7t7 '(,.., .c�?` - -_-- PROPERTY LINE 4 L` Oh'�.VIL A;':G t __ MEHN HIGH WATER ' SCALE.• AS INDICATED DATE ID - ZZ-�yj ._ BENCH ".AIARK '','',��` �•'�'_��`_�'' ?- ��._.__ � .�'_ �': �. MARSH • � _ war. A4 wARwICK a ,v ssc}cla,rEs BOX 80 - Nt>RTH FAL1Yfc?( TN 4 1 5 6 t'HUSE T I ' C? S