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HomeMy WebLinkAbout0228 BUMPS RIVER ROAD - Health 228 Bumps River Road, Osterville a lit --\ems 0 NoV v v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0(pplitation for bisposar *pBtrm Construction flermit Application for a Permit to Construct( ) Repair W Upgrade( ) Abandon( ) ❑Complete System Y Individual Components Location Address or Lot No. XI'a Bumps P fLtEr-PLD Owner's Dame,Address,and Tel.No. Assessor's Map/Parcel ( GC V[UA4.6 e—.r le.fC &IX Installer's Name,Address,and Te.No. 5c?2- —L'ZZ s"Z 7 Designer's Name,Address,and Tel.No. Pog - ' 4 004-e0 . cute '5 L NIA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures Design Flow(min.required) gpd Design flow provided /J� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) T4j5uL( ) 8-26 D79C)Ic_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ` gned Date ' Application Approved by Date Application Disapproved by Date for the following reasons Permit No. pri to 3 Date Issued 4 •I No UJ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliCation for Disposal 6psteUY Construction Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ;1% Bumps p.(u6L Jkj> Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ' d • PA►(- p C+{C-RA(( L 45S((.44 MA * Installer's Name,Address,and Tel No. 5o2-471 -$$17 Designer's Name,Address,and Tel.No. Rogcc3 ovp-eo . NIA = Type of Building: t Dwelling No.of Bedrooms' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building -No.of Persons Showers( ) Cafeteria( ) ', Other Fixtures Design Flow(min.required) gpd Design flow provided w�� gpd -• Plan Date Number of sheets a Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil / I Nature of Repairs or Alterations(Answer when applicable) '� �j'� ,� �` t� (� j�.. l?z��1C (���L1 SAx, - Date last inspected: 5 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code.and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Date Application Approved by Date G� Application Disapproved by Date for the following reasons Permit No 9--,09 Date Issued ' 16Z en - - - - ---------- ----- --------------- �- - - --------------------- t' \ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliarue THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by R OG&—;;.-r G Q O E- at a;t FS 63UM?S 1LiUX�.Rh �5 T' has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No -d 6 3 dated Installer RU PJ- ex)4L cp Designer N A #bedrooms tj ;/ Approved design flow (\ I/a gpd The issuance of this p rmit s all not be construed as a guarantee that the system will f i ct a design Date U Inspector �lJ . -------------}}--� - '---�D-/-------- --------------------------- ------------------------ -------------- --Fee----- ------------ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30iBtJDsal 6pstettt Construction 3PerIUit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon �►( ) .System located at ���?� y� � ��U GL. O ST,S DU I L 05 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m st be c%m�pleted within three years of the date of this pe Date , Ct Approved by tti Town of Barnstable Inspectional Services r "kNS ABUL %W. Public Health Division -200 Main Street, Hyannis MA 02601 Office: 508-862-4644 ti` Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4988 1470 March 2, 2020 VASSIL, PAUL R& CHERYL A 44 MAPLE VILLAGE CT BERNARDSVILLE,NJ 07924 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 228 Bumps River Road, Osterville was inspected on 02/21/2020 by Michael Sears, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: o The distribution box is rotted. You are ordered to replace the distribution box within one (1)year from the date you receive this notification. , Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH QTac ean, R.S., Agent of the Board of Health I Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\228 Bumps River Road Osterville.doc - P Town of Barnstable • 6ARN7SfAHL& b 9 Inspectional Services Department AT fo may. Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6; 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in.the distribution box above outlet invert due to an overloaded or clogged-SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well o Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20'h) OTHER KO ffe� box Repair deadline: Q:ISEPTICIDEADLINES TO REPAIR FAILED SXSTEMS.doc Commonwealth of Massachusetts 1 67Q"' / 00 Title 5 Official Inspection Form A +- lI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r, 228 Bumps River Rd. Property Address Pual Vassil Owner Owner's Name ` information is required for every Osteryille Ma. 02655 2-21-20 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. Inspector Information /14383 ' filling out forms on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path Company r� Company Address South Yarmouth Ma: 02664 City/Town State Zip Code 508-477-7788 SI114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ PassesOF 2. ® Conditionally Passes �+ �. MICHAEL N 3. ❑ Needs Further Evaluation by the Local Approving Authority 'o: SEARS No.SI14430 :Go 4. ❑ Fails �,� �o ; i, i�ni ill 1111 N S Pt�G�p�`�• 2-21-20 Inspector's Si ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original form should be sent to the system owner and copies sent to the buyer, if applicable, and.the approving authority. P Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 228 Bumps River Rd. Property Address Pual Vassil Owner Owner's Name information is required for every Osterville Ma. 02655 2-21-20 . page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): D box is callapsing needs to be replaced t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts �- Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........... �!% 228 Bumps River Rd. u� Property Address Pual Vassil Owner Owner's Name information is Osterville Ma. 02655 2-21-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 228 Bumps River Rd Property Address Pual Vassil Owner Owner's Name information is req u I red fo r eve ry Osterville Ma. 02655 2-21-20 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other. F 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No i ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form ire Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..............c 228 Bumps River Rd u Property Address Pual Vassil Owner Owner's Name information is Osterville Ma. 02655 2-21-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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 El tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and' chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of•2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 11 Area—IWPA) or a mapped Zone 11 of a public water supply well a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Bumps River Rd Property Address Pual Vassil Owner Owner's Name information is Osterville Ma. 02655 2-21-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? El ® 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. El ® Determined in the field (if any of the failure criteria related to Part C is at Tissue approximation of distance is unacceptable) [310 CMR 15.302(5)] f a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I Commonwealth of Massachusetts �n Title 5 Official Inspection Form ii; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 228 Bumps River Rd. u Property Address Pual Vassil Owner Owner's Name information is required for every Osterville Ma. 02655 -2-21-20 page. City/Town State Zip Code Date of Inspection D. System Information , 1. 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 Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes'® No information in this report.) Laundry system inspected? ❑ Yes ® No . . Seasonal use?: ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2018- 158000ga12019- 115000ga1 Detail: Sump pump? : ' ❑ Yes ® No Last date of occupancy: NA Date f l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18. ". P Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 228 Bumps River Rd Property Address Pual Vassil Owner Owner's Name information is Osterville Ma. 02655 2-21-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 i Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No i Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): ` 3. Pumping Records: Source of information: NA ' k Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts �n ,tip Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Bumps River Rd. Property Address Pual Vassil Owner Owner's Name information is required for every Osterville Ma. 02655 2-21-20 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool x ❑ Overflow cesspool ❑ Privy ' Y ❑ 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): Approximate age of all components, date installed (if known) and source of information: NA , Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 'Depth below grade: 40"feet Material of construction: ® cast iron ❑40 PVC 1. ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I. I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 228 Bumps River Rd u� Property Address ' Pual Vassil Owner Owner's Name information is Osterville Ma. 02655 2-21-20 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 30" Depth below grade: feet Material of construction: ; ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) " outlet cover at 30" below,grade 1000 al tank inlet cover at 16 below grade, g 0 9 , 9 Inlet tee outlet baffle If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) . ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: .. Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 611 Distance from top of scum to top of outlet the or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? sludge Budge tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,' liquid levels as related to outlet invert, evidence of leakage, etc.): inlet tee, outlet baffle t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 228 Bumps River Rd Property Address Pual Vassil Owner Owner's Name information is Osteryille Ma. 02655 2-21-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 228 Bumps River Rd Property Address Pual Vassil Owner Owner's Name information is Osterville Ma. 02655 2-21-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes i] 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 9. 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 no good 44" below grade under rail road ties box is 16x16 with 1 outlet t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 228 Bumps River Rd. V� Property Address Pual Vassil ' Owner Owner's Name information is required for every Osterville Ma. 02655 2-21-20- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' r 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: SAS is 1000 gal pit located with camera clean and dry no sign of failure Type: _ , ® leaching pits number: 17 1000 gal ❑ ' leaching chambers number: , ❑ .leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number;dimensions: , ❑ overflow cesspool number: , ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form + III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 228 Bumps River Rd. V Property Address Pual Vassil Owner Owner's Name information is required for every Osterville Ma. 02655 2-21-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1000 gallon pit in good working order, located on site _ 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 C Commonwealth of Massachusetts �n Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 228 Bumps River Rd. Property Address Pual Vassil Owner Owner's Name ' information is required for every Clsterville Ma. 02655 2-21-20 page. CitylTown State. Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 s Commonwealth of Massachusetts +� Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 228 Bumps River Rd. Property Address Pual Vassil Owner Owner's Name information is required for every Osterville Ma. 02655 2-21-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 ` Rea r I 3 y Al -31.6 A_ ),R.6 a_ 3 ct,b • 3- a$.6 3- q5, 6 - �, 30 q- sN t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 228 Bumps River Rd. u- Property Address Pual Vassil Owner Owner's Name information is required for every Osterville Ma. 02655 2-21-20 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ; ® Surface water ® Check cellar ® Shallow wells, NA Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: r You must describe how you established the high ground water elevation: Hand auger to 15' bottom of pit at 12' no water 3' below pit r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........ ... 228 Bumps River Rd u - Property Address Pual Vassil Owner Owner's Name information is required for every Osterville Ma. 02655 2-21-20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate t ;• 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included Grwok �o of 14 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts UUHY Executive Office of Environmental Affairs Department of Environmental Protection VAMM F.Weld Trudy Co:e sal. or GammArgeo Paul GUucd ecomnr.+onwl u.ctWA„a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - - - - - PART A.- CERTIFICATION 9 Z 2$ Out-+ps AuJM PLO. os ,2�tL 0 Property Address: A ress of Owner: Date of Inspection: 9 (if different) S � Name of Inspector: L/}W 1Ltnj ce— Company Name,Address and Telephone Number: MA-Sod —. AL- SOLVICeC INC- p2SSA ©'1 po , gax 4-S-o Poc�Se-r I MA 5f3�3 -s6q — (o!o 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _V Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspectors Signature: O Date: 1 4.9 W The System Inspector shall submit a copy of this inspection re rt to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A] PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or ezfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Wlrtter Street a Boston,Massachusetts 02108 • FAX(617)358-10+9 • Telephone(617)292-5500 w Pnmad on RecKkd Pacer _ . 9v1� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B)SYSTEM CONDITIONALLY PASSES(continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed ,0,ipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the ,,.Board of Health): . -__.- --_----_--_. broken pipe(s) are replaced. _- obstruction is removed - - distribution box is levelled or replaced _ The system required pumping more than four 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 Cl FURTHER EVALUATION 15 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 1S NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private ureter supply well, unless a well water analysis 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• 3) OTHER (revised.11/03/95) 2 ,ffA FORM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART A CERTIFICATION (continued) Property Address: Z L 8 SUMPS R 1%1C12 R0. 0 S 7L-nA,'I c-t.L:r' Owner. KeVW H- V4L-y Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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 paty well analysis no acceptable water quality analysis. if the well has been analyzed to be acceptable, attach copy of well ter coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant dwea to public health and safety and the environment because one or more of the following conditions exist: 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 0 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for fuither information. (revised 11/03/95) 3 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Zg 6L'.M�s ST�Jl L, z 21vL Rp. o itG Property Address: _ Owner: k e Vi rJ 14 e-P L y Date of.Inspection: I ^_ 9� Check if the(following have been done: V Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving nomtal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZAs built plans have been obtained and examined. Note if they are not available with WA. -The facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. V All system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2Z8 13tar+PS tt1%kY)- dSTen✓iI.LC Owner: K.GV)rJ L.Y Date of Inspection: '+—14,9(42 FLOW CONDITIONS RESIDENTIAL: Design flow: 330aallons Number of bedrooms: -S Number of current residents: Garbage grinder(yes or no):Z Laundry connected to system(yes or no): Seasonal use(yes or no):A6�2 I 2 3 2 t'co Water meter readings, if available: — 157 Z eco pAzt _ W p�IL auJou"n Last date of occupancy. fX�y I�'O pSt�lNTlr`� COMMERCIAUI N DUSTRIAU Type of establishment: Design flow_Olons/day 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 0 A49ca 0 5 Or LVV*2 g e- PuM Q„� AND owx ) System pumped as part of inspection: (yes or no)ALO W If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tankidistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: orS Sewage odors detected when arriving at the site: (yes or no)An (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 225 6vmeS aiveyL $71'�V 1 t✓ � Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) j/ Depth below grade: 2 Material of construction: �cencrete,_metal._FRP other(explain) - -- - Dimensions: L X 13e-e7-4 Sludge depth: O (ate curter) Distance from top of sludge to bottom of outlet tee or baffle:- Scum thickness:�T OVTtk'-'r) Distance from top of scum to top of outlet tee or baffle- Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relat o to outlet invert,structural integrity, evidence of leakage, etc.) PVC- )/f s C-/2 vJ cr r /J /V O VV40ownn S DA/ J4 Jr� GREASE TRAP: gocate on site plan) Depth below grade: . Material of construction: _concrete_metal _FRP other(explain) Dimensions: Scum thitkrwss: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,stnxwal integrity, evidence of leakage,etc) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANV:A,4 (locate on site plan) Depth below grade: Material of construction:. concrete —metal _FRP other(explain) Dimensions: Gpadtr ttallons Design flow:aallons/day Alarm level:_ Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX:140T FOUND 'r' ROLL:;' W PrS PU 61 (^i �'A DF S W)n1CL T-)'FS (W(W'j 4�) (locate on site plan) F2orti 9-9—(3vI L t PLArj $Y oa S00L.L cO u"T'L C'"T 'Q I PI- F Z0j k Tom) (v o( 9M P L'%J �C vt_A4Z j 11L'AO S Depth of liquid level above outlet invert � LA+�pSc 0 j M�t�! W v,i DE'Q LorjOSCAet- S \ Comments: J (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER:AA (locate on site plan) Pumps in working order:(yes or no) Cornrnents: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSA L SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Z Z 8. &,m P S 2\vi-m 2 o . &S-rm tl1 L l_E Owner: YWONJ I+e-PrL '( Date of Inspection: 't _ 9(o SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: L far-rJ Dal SCaL tM RS—&/1 Ll ?osrr L t.�oft K c nrSr2�/G 1`h ri #�$F}-31 t� Type: leaching pits, number leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) ^rd S IlrhU YQa PWC I Pc~r►0 IN C, CESSPOOLS: AIM- (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• Ind'Kation of groundwater. inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:41P (loate,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.) (revised 11/03/95) 8 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2-Z 8 GUMJ3S 2%vL-'n /L p FPST�2 V 1.LLB MA Owner: KCZI)O E{VA-L y Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks 2-9 37.5' locate all wells within I00' aerc� of �5� A f4eT%-0: Dr-cK I . I 5 5 L4C 1d) Q I, L o�„f� ZE S CH 1Er 2LS ArN1 IV r, LeRt�}v� f'tL P+T 1 t � Arpw<- f.x�T-t�nl DEPTH TO GROUNDWATER E STI N groundwater I Z feet Depot to grounr.m �,c y-10� P�r1 j method of determination or approximation: �t S Po S�- W047-tC S Cb&l T-k AQ2 rc sT moLC7 4 Z4-SY d Cor+TnAcr� -�n�s ra✓cTlay s ao a uouu p air T(M�c Cti� 1�1 s Pe cT moral 1 (revised 11/03/95) 9 OF BARNSTABLF.. LOCATION_. _ hyw S v c '"'%ASEWAGE # 3 16 VILLAG N� ASSESSOR'S MAP Cr LOT___��t INSTALLER'S NAME & PHONE NO. '�. ���5Co�1 -n SEPllC TANK CAPACITY t i 00d f)oA6V,3 LEACHING FACILITY:(type) Q'� (size) ,� q, 6k,5 V . NO. 0F BEDROOMS +PRIVATE WELL OR PiIBLI�W T I j BUILDER OR OWNER �G` yi� SCo, DATE PERMIT ISSUED: DATE COMPLIANCE !SSUED: VARIANCE GRANTED: Yes No � �1 /_� �� �l7 ,Z ,�/ 9 .�y� �� . . -. ►.� usl� NT � , First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402 5357 9189 1908 52 United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal Service j I Town of Barnstable I "•,�`� Health Division 200 Main Street ' Hyannis,MA 02601. i I C,3,�IPLETE THIS SECTION ON DELIVE0 • Complete items 1,2,and 3. -,Si'&)! 7e 0Z]Agent • Print your name and address on the reverse --4-" t t t 0 Addressee so that we can return the card to you. t is to c f t m ilp c vK eceiv d ?rinted t4arne) C,,�te of Pelivery • Attach this card to the back of the mailpiece, y t if space c p rmlts C, or on the front if space permits. addresA differk from item I? Oyei r delivery a tlress below: 0 No L PAUL �"VASSI , R&CHER RAP, V4--MAPLE VILLAGE CT .. BERNARDSVILLE, NJ 0792 -3—S2Nide Type 0 Priority Mail Express® 0 Adult Signature 0 Registered MalITM ?[]Adu,k Signature Restricted Delivery 0 Registered Mail Restricted C.r,fi.d Mail® :tIiuvme ry C 9590 9402 5357 9189 1908 52 Certified M2 Restricted Delivery Receipt for Merchandise 0 Collect on Delivery Ifiv TM D ati'l.-N,.Im�Ar-tTransfer-frori�sety�ce I�bpl) L-j Collect on Delivery Restricted Delivery 0 Signature Confirmation El Signature Confirmation ?018"*'1?30 0001 498'8' 106 ' ''fail Restricted Delivery Restricted Delivery PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt C3 .. • f- a - coCertified Mail Fee /,! s Extra Services&Fees(check box,add lee as appropriate) ❑Return Receipt(hardcopy) $ ❑Return Receipt(electronic) $ '14a,r, Postmark 0 .❑Certified Mail Restricted Delivery $ /y Here 3 ❑Adult Signature Requlred $ ❑Adult Signature Restricted Delivery$ a f - --- rn _ VASSIL, PAUL.R&CHER`I�LA `^ �' 44 MAPLE.VIL'LAGE(CT 4' a A -,, .. r C3 - BERNARDSVILLE;NJ-07924 Certified Mail service provides the following benefits: •A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this. delivery. USPS®-postmarked Certified Mail receipt to the J ■A record of delivery(including the recipient's retail associate. signature)that Is retained by the Postal Service'" Restricted delivery service,which provides c for a specified period. delivery to the addressee specified by name,or' to the addressee's authorized agent. .9 Important Reminders: Adult signature service,which requires the fx ■You may purchase Certified Mail service with signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retaiq. or Priority Mail®service. Adult signature restricted delivery service,which' ■Certified Mail service is notavailable for,. requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified, ■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent} with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the •To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a- certain Priority Mail items. USPS postmark.If you would like a postmark on •For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office'"for the following services: postmarking.if you don't need a postmark on thisT Return receipt service,which provides a record .•Certified Mail receipt,detach the barcoded portion I of delivery(including the recipients signature).f 9 P 9 ) of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.` electronic version.For a hardeopy return receipt, complete PS Form 3811,Domestic Retum Receipt,•attach PS Form 3811 to your mailpiece; IMPORTANT:Save thIs recelpt for your records. PS Form 38O0,April 2015(Reverse)PSN 7530-02-000-9047 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '.�C.c... /J.............OF... 6h�./..'10V4 ................................... Appliration for Disposal Murky Tonstrurtion 11rrutit Application is hereby made for a Permit to Construct (V-) or Repair ( ) an Individual Sewage Disposal Y� S at: < r, ...........:. �!.N_1 .: ..... ../✓l /L.I . ......... ...---...-----=C.,. ... .................._..._........._.......... . Locatid Address or Lot No. Addr ... e'�1 0��-!G :�,/ ►ess ...• � -=............... Installer Address . �'`''�S Type of Building Size Lot...�.�1 feet............... q. aDwelling—No. of Bedrooms.............. .........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -----•--•--•--••----•--••...............................••••-......--. Design Flow.......... a......................gallons per person per day. Total daily flow..=...... 3.�....................gallons. W _ C4 Septic Tank—Liquid capacity/4.d._.gallons Length/v- L. Width.-S�"�'---. Diameter................Depth...?......... W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. x 3 Seepage Pit,No--------------------- Diameter..................... Depth below inlet.. .............. Total leaching area-.2./. .!Jlsq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.._ .. r��><? ' ... e" ................. Date..�/ 4':r p_.._._ a P � Depth ground •-------..�.. ��... M Test Pit No. 1...LZ.._..minutes erinch Depth of Test Pit.�__..�! _........ D th to ound water>Z.�4..._.... LL, Test Pit No. 2................minutes per inch Depth of Test Pit...........___..... Depth to ground water........................ ------------------------ •---...... -.?............:................•-•••--••-•-•--••••••-•-.............._..•-•_...... O Description of Soil----52 -�._.... -z'� __y _...... 2 =- "- /-'r ---------------------------------- -------•...... 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 TITL P; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued by the board of li lth. Signed.. /�qo.� �r '_= ------•---•-.... �11 -- ----- ------ Date Application Approved By........... .. -� •� v -----: .--•a�� `�' ,•�-��-.?.. ..----^•-•---•-----•----•-•--------^ Date. ' V'%pplica.tion Disapproved for the following reasons:...............i. ----.....-•..................•--------•-•-----....------•---------.......•........--........-•-•---•-•--.I•--..:--••-----•...........---••••••--•••.......-------•-•------------•-........-•••--...._.._ Permit No..`�..5�.._...��-1.fn....._....-•---......... Issued........................................... Date ...._ I Date _ ----------------------------------.-----------,---------------------- THE COMMONWEALTH OF MASSACHUSETTS _ - BOARD OF HEALTH ire ..........OF....... ................... (1rrtifutttr of Toutphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O' or Repaired ( ) bY................. �'��... n a /.. r= ;•J A� -`S• ..................•-----------------•-----••--••----••----•--•---........._........_ .....r r Installer at. !^ //� -�-'� J�1j/�� -*'= �/ l °"�`-a •-- . $. rya n... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE._... - ------ � r/ ......... Inspector. a ,. ��... lJ,��.,,/, ........................... v -----•-------------------------------------------- ---------- ------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF._...... ��L � :.5. 19,, L.( ............ No......................... FzK......................... Disposal Works Tonstrurtion f rrutit Permission is hereby granted......... _� .! :. ='--._ ,:_..,! ? >"1'ice._._.•.................. to Construct (x) or Repair ( ) an Individual Sewage Disposal System f at No........... :.-a7r.�l' .4._:s 'l c. �� !._.._. I5 .........................---- • .. I Street Y as shown on the application for Disposal Works Construction Permit No.. .a?l _ Dated.......................................... Board of Health DATE................................................................................ c 41 THE COMMONWEALTH OF MASSACHUSETTS BOARD O�JF� )HEALJT�H Appliratiun for %papal Works Tonstrur#inn jhrmi# Application is hereby made fo; a Permit to Construct or Repair ( ) an Individual Sewage Disposal System tirrv. 2.Pst_�... �'t/�. 2..�................... .............. JLI...... .........................__......._.. ocatio -Address or No. ,�� - r�d_. d''�. �.,r,�` •'yl �J s- .............. .......$f,1". �,,�.!I!. e9s V Installer Address Type of Building Size Lot....l��� feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `PL44 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtu es ..... Q W Design Flow..........:mil.............................gallons per person per day. Total daily flow..........s�....._.........................gallons. WSeptic Tank—Liquid capacityhe d..gallons Length 46_r:�6. Width_.:r.�r�... Diameter................ Depth............ x Disposal Trench—No..................... Width.................... Total Length...... ..�._....__ Total leaching area_..............._--sq. it. 3 Seepage Pit No..................... Diameter.................... Depth below inlet...C.............. Total leaching area.9.9 sq. ft. Z Other Distribution box ( ) Dosing ( ) J ,p - ,/ /I Percolation Test Results Performed bY.__.Cl.�.. 1� 'lOd N...1._...``fir.................... Date_..T Z-T��---- r.. 14 Test Pit No. 1----------------minutes per inch Depth of Test Pit.......- .......... Depth to ground water-.--/._�._..._..... ti Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....--.................. p+ ----------------------------•--...................._. v....-- ....................................................._.....-- O Description of Soil...... Z..... - G?, .�...--- Z ............ ...V -------------- ••-------- .... -�' ....4.. :!J..1Y1 _ }j'�✓ ......... _......._......... VW ..............•----------------••--------------....-----••----------•---------------......---•---•---------•---------------------------•----...........-----..._.............._.........-------•----.... 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 iITIS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has PTn issu b e board of I th. 0,9 {� Date Application Approved By......... -1J._. ....................................- .......7..• 1a. ly .Date Application Disapproved for the follouring reasons:........................................................................................................---- •--------------------•----•--.............---....---.........---------•----...------•-•-----------....._.....---................................------------..................--••••-•-...._......__.._ DatePermit No.--:LZ..?......3_Z C-----------------__.... Issued......................................... Date ,A IN �a 11-77 31. 3 171A 3119 3/.+o j .20 i / i I / l��}L• � f � �-? yd t i '�/T '/ fi�,,,y 7C/'�LC � �, �t I Tom. 57 P 7� -r/Ol / ft r- o _ �'�t-� _ � `� 2. _ �v�r � _ � S� _ _�_�_Sf>�'�c/ G_Q rr�_':✓'?A 7'i.^/dS „� .. � �-- ? L 3 L CAI 41 Sr _s �y r / /t �y 7 S /4� %1 t .'�4_.) f /. r //- // �< 1 Al fC ' � . 1 / 3 �¢ ! — Z 3 d��_ fir �'A/A�/i 1` =/S"v ,� s' _ �,"�vh•- LOA�i.�rr �� _u` .. S%'. �.d '~�, �O/G ?`.�T-.�G�iti�J , ��" p/t/ ¢/f` ��• ! uSE JQ���: 5..s ' �',!' f�': :�C .��- ;�islf r.'/�.� � :�.�' ,G''is :f.i� '�f�'YS .,�•�-;���. N��+ir f'�R• f .�M,%r Gr -. �y: �����:/ �V � / � i^ "-/. r' �V.�7 �aa .r � "V ' �+ �� Iw,� /' ,,..yy f � a / .H:� 1" �..���!/�.� � ' y�f�.r�a -�:�,,..'V'P y` M .•� (,/.� �-T� �Y��/ Dwitr' d� t •N /! i3L f� 'ElSi i 41 a t r 79 ELL � o ' r � � (� • i 101 SCALE DRAWN By DATE VY REVISED ri i f 'r j.