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HomeMy WebLinkAbout0379 BUMPS RIVER ROAD - Health 379 Bumps River Road, Osterville A= U Commonwealth of Massachusetts Nq Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � y v 379 Bumps River Rd Property Address a hJ Mulherin Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 pace.I 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. A. Inspector Information /* mql d Frank Nunes Ill Name of Inspector ro saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 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. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/29/20 Inspecto Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater;the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 379 Bumps River Rd + Property Address Mulherin Owner Owners Name �.l information is required for every Osterville- MA 02655 9/29/20 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. j 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin Owner Owner s Name information is required for every Osterville MA 02655 9/29/20 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 bellow): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain bellow): ❑ 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 10 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin t Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 page. Cityrrown 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: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin Owner Owners Name " information is required.for every Osterville MA 02655 9/29/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) E 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 ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %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. 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 ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin t Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 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: 3 bedroom permit and plan on file at BOH Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry ry on aseparate sewage system? (Include laundrys stem inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin it Owner Owner's Name - information is required for every Osterville MA 02655 9/29/20 page. CityfTown 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2 yrs ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: . gallons H'ow 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •u 379 Bumps River Rd Property Address Mulherin Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: z Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1985 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 379 Bumps River Rd Property Address Mulherin Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness Trace Distance from top of scum to top of outlet tee or baffle >211 >2" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin t Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 page. Cityfrown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin `1 Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) I 8. Tight or Holding Tank(cont.) 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 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 was video inspected, no adverse conditions observed t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits, number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 379 Bumps River Rd Property Address Owner Mulherin information is Owner's Name required for every Osterville MA 02655 9/29/20 page. Cityrrown 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.): Leach pit is 3' below grade, cover raised to 6" of grade, there is 2'6"of effluent at this time, sidewalls are clean above the current level 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin l Owner information is Owner's Name required for every Osteryille MA 02655 9/29/20 page. City/Town 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 Commonwealth of Massachusetts ,a Title 5 official Inspection Form I° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin Owner Owner's Name information is required for every Osterville MA 02655 9/29/20 page. Citylrown 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 30 �(° L 3� C� t /O C5�- - ��. 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 .�e 379 Bumps River Rd Property Address Mulherin 1s Owner Owners Name ' information is required for every Osterville MA 02655 9/29/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >12 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: 1985 NGW 12' Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4'seperation per 1985 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: , TOPO mapping shows the site at 34'msl and nearby surface water at 11'msl You must describe how you established the high ground water elevation: , See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 c� Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 379 Bumps River Rd Property Address Mulherin w Owner Owner's Name information is.,. required for every Osterville MA 02655 9/29/20 page. Cityrrown 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 ® G. Inspection Summary: 1; 2, 3, or 5 completed as appropriate 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 Fz)r 15: Explanation of estimated depth to high groundwater included 4 1 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 A� Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of JAN 3 1996 Environmental Protection � I Aag s �C William F.Weld CV Governor Trudy Coxe Secret",EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 31C06-rva (c,.;;2 Ptz — © C'r.:.�1a Address of Owner: 3SU logo?tc v l Date of Inspection: -D CL. �a����(S (If different) -Reva.-s v //"/ 'Al y Name of Inspector: 3, �c t`lc rx\l,s ref �08 Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and 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: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �/ / Date: % CL.. %.5j /9%CS The System Inspector shall submit a copy of this inspection report 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) SYSTEM 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) 9at'STEM 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 exfiltration, 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. 1 revised 8/i5/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617) 556-1049 • Telephone(617)292-5500 `i Pnnteo on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31q�3v I . Owner: Date •,i Inspection: sec tad tciC�s BI SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(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 pipets) are replaced obstruction is removed CI 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 the public health, safety and the.environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS 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 surtace 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 water 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. DI 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. revised 8/15/951 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: D-lvn� Owner: -R%c_�Aru s•t Date of Inspection: -Oct,. I a) I Ci 1 Sl DJ SYSTEM FAILS (continued),IVA 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 supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is.10,000 gpd or greater (Large System) and the system is a significant threat 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 II 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 further information. • revised 8/15/95) 3 SU BSURFACE SEWAGE DISPOSA L SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 'RtCto), o S '-Ov% Date of Inspection: -bcC \a,'k o - Check if the following have been done: Z�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 normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. .t,� As built plans have been obtained and examined. Note if they are not available with N/A. :fhe facility or dwelling was inspected for signs of sewage back-up. �he system does not receive non-sanitary or industrial waste flow Zfhe site was inspected for signs of breakout. 1,-'All system components, excluding the Soil Absorption System, have been located on the site. _L-'T_he 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. _L--fh_e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. zf"T'he facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub Surface Disposal System. revised 8/15/95; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: ,��ra Date of Inspection: lec. Qs)(r,5i_ FLOW CONDITIONS RESIDENTIAL: _ Design flow: 330 gallons Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_hJ0 Laundry connected to system (yes or no):yCS Seasonal use (yes or no):�e s Water meter readings, if available: Last date of occupancy: S tDi, �445 COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/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: System pumped as part of inspection: (yes or no) i o If yes, volume pumped: t allons Reason for pumping: TYPE OF SYSTEM _�eptic tank/distribution 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: s✓/i�/� f�j�/�CN /9 Sewage odors detected when arriving at the site: (yes or no)L-1 • ;revised U15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 Owner: Date of Inspection: SEPTIC TANK:_ j�t7 (locate on site plan) Depth below grade: Id,1.4 Material of construction: Z-Oncrete _metal _FRP _other(explain) Dimensions: 4 Sludge depth: oq'—�( , Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: O 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 �^d outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) �iJh :%I C�OC�0 1SHADE GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) • revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -� SYSTEM INFORMATION (continued) Property Address: �7�i 3"m�' �`"`'Z- \C�' L�=Tr:�.�� Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: Qallons Design flow: Rallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Even Comments: / (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)_ PUMP CHAMBER:_ (.locate on site plan) Pumps in working order.(yes or no) Comments: (note.condition of pump chamber, condition of pumps and appurtenances, etc.) r , ;revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 7 Owner: Z.c�,�r� S T ro,1 Date of Inspection: Jc C , \-ai �et'1 5- 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: - Type: leaching pits, number:- �)��� yyk. 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.) AID CESSPOOLS: — (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 (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: (locate on site plan) Dimensions: Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 8 ,revised 8/15i95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (SYSTEM INFORMATION (continued) Property Address: 3`l c( 13�w.,p s RI L� Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Gc��ac E INS k, A 1 n� DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: ;revised 8/15/95) 9 1 No..- 9�t-/a�1 Fps....... .�............... "—TH'� COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH •- .- Apptiration for Uhipo,sal Works Tonstrtirtiun Prrutit Application is hereby made for a Permit to Construct ( ,�'or Repair ( ) an Individual Sewage Disposal System at: ......(,� ....[.:lr....... 5.....iK-... ...... ST. .I I,L'��M��S ....................... Location-A ress t . or No. ............-... . i� Z /�fJry l S M 5.............................. Owner .. .... ..........• -`�.-C- '- �- ............................... Pq Installer Address Type of Building Size Lot.... ...Sq. feet U Dwelling—No. of Bedrooms.......2J................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other xtures -------------------------•------ W Design Flow....................................:......gallons per person per day. Total daily flow__._._._..._.��.__.... ...............gallons. WSeptic Tank—Liquid*capacityl-P. —gallons Length 3!TP..... Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--_._.__---I......�. Diameter.....1,0...._..... Depth below inlet_.............. Total leaching areaZ4!.!?....sq. ft. Z Other Distribution box (✓) Dosing tank ( ) Percolation Test Results Performed by---LUAt 1JA ._ CX:.......................... Date........ F' ,aa Test Pit No. 1...42.....minutes per inch Depth of Test Pit........ Z 1-__-- Depth to ground water.....N.Q M... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W ...................................-------- ................................... Description of Soil------------ z------..� .Q .S[� a 1 C�f Z _ b.l 1� ........................... 11 x W UNature 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'I'L4: 5 of the State Sanitary Code—Th un rsigned further agrees not to place the system in operation until a Certificate of Compliance has bee is b th oar o health. Signed----- -- ------- -------- - --- - --- ----------------------------- / Application Approved By................ .... ....... --------------- --. .................... Date Application Disapproved for the following reasons-----------------------------•-------•-------------------------•-------------•--•---------------------.....--•--- ..................................---------•----•-••-------------------------------•-•---•------------..__....-----•--•---------------------------•--- ------------...... ........ ..... ....... ....... � �' Date . Permit No...,..--=-'q g • -- . Issued._.. I-' ---------••----...---•---- -------- Date L 4 NO.----`d--f/ Fps...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH. In ...-----.OF.......i/. �............� :to Appliratiou for llhiposa1 Works Tottotrurtiou Prrutit Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal System at: .. •-Location-Address _ or Lot No. - ... - _ n Own! ddre Installer Address QType of Building Size Lot---�._ y-_1__�� ....Sq. feet V Dwelling—No. of Bedrooms__._..�J..................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of.Building No. of persons............................ Showers — Cafeteria Q1 Oth `fixtures .......................... . Design Flow.......__.2................................gallons per person per day. Total daily flow............. �-'...............................gallons. 1:4 Septic Tank—Liquid capacitvl(G44...gallons Length f�.l-P...... Width................ Diameter................ Depth_.............. Disposal Trench—No. .................... Width_..................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No-----------1t........ Diameter.._.1_._.._..._. Depth below inlet...... Total leaching,are04�7_e.....sq. ft. Z Other Distribution box (V/) Dosing tank ( ) Percolation Test Results Performed by._ .21•�%ti 4 _�5 oG---------------••------_-- Date....... �a Test Pit No. 1_. _ ______minutes per inch Depth of Test pit.......1_Z________ Depth to ground water --Nam_----- (i Test Pit No. 2................minutes per inch Depth of Test Pit-_-______-____--_--- Depth to ground water--._____-____•_--__.-_-- p ••..;---••--------------•----••---•-•.......-•••....•••__ •--•---•-•--......-••-•-__--- ••_---............. O Description of Soil........... _......... t%-��c/S v t3 � 1 L} 2 ` ...............................................�1 J /�lV 1� x U ------------------------------------- -------------------- ---------------------------------------------------------------------------------------------------------------------W ••-•-•--•---•----------------•---•-•------•-•••---•----------•-•--•-••••-•-•••-•••••••-----••••-••••----••-•••••-------------------••-•-----•----•-•••-------•••-•-•-•••••••••......•-••.....•-••--_.... UNature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— Thp un ersigned further agrees not to place th system in operation until a Certificate of Compliance has been i d bq th boar, health. ti / Signed• --.=�� ...���r ...... ` �! ......... .. ` ... .„Y__ ` D ad t Application Approved By...............=---•--••-•--------......" z ..: _ Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ---------------------------•------...--------------------------------.........--•--------------------•--••----•----•----•-•--------------------••---•-----•-----•--•••••---•••---------•-•---•-......_ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD, OF HEALT PIC- � � .ram (Errtifirate of Tootpliatta THIS S TO C TIFY, Th t th IndivicLu_al Sew e Diapctsal System constructed 1(✓'� or Repaired ( ) .r-- by-•---•-_•_.. . (. % '. ... �/1-f.......... ............... - .- S "tf,x� w has been installed in accordance with the provisions of T��" /-�5 of he S ate Sanitary Code as described in the- application for Disposal Works Construction Permit No__________________________G_,__�_...... dated----............................................ THE ISSUANCf OF THIS CERTIFICATE SHALL NOT BE CO STRUE® AS A GUARANTEE THAT THE SYSTEM WILL FU CTI N SATISFACTORY. DATE........... ?'5--------------_-------------- . Inspector....----- THE COMMONWEALTH OF MASSAC SETTS BOARD PF HEALTH t.. 'e �. 1 �' G . ...........OF.... ...... ,�f ....................... No........ ............. FEE...___._-__............ �to�ros�t � ore11`� ✓Permisslon is ereby .._.L _ �.... ..,rua!ne..l_�er_�tit / 1 ...' :. to GbnstL=t ) or it ( ) an Indivldual_)Sf'wage Disposal Sys em.-i f at o..--•... -- -•-- Street as shown on the application for Disposal Works Construction Permit No...................... .................. Dated............................................ �j Board of Health DATE....................../ = / ....... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS SATE PLAN SHEET /OF 2 SCALE. I,,. o, 9� L LeAGa-1�:.PaiS�rJ is Ai,, 6e;FTLG7-AWIG _ N Q , \ r L4 1Z C.vT 11 1 It0).aFl` t, lti N FOR 0"IZ-:-I, _ REG/STEREO LAND SURVEYOR �dT I'Z t�uM pr 1?Iu ZON E � � 4 C-- i M A 4,5-, PLAN REF. DATE 1 I1 01 BENCH MARK DATUM WM. M. WARWICK .8 ASSOC., INC. DOMESTIC WATER SOURCE " . BOX 801 - NORTH FAL MOUTH u y FLOOD ZONE. ►JD N ' q-A MASS. 02556 - (617) 56,E-26 3B ' L�I1 NIIVG' 81451 PI SECTION NOT, TO SCALE Shccrl z of z 24C.I.MH 00VER 1 FARTH F/L , .BRICK AND MORTAR COURSES AS RfO'O• TO BRING t ' � All;^� _.r•s�, w8 Ow � _ • COVER TO GRADE INLET -J- i _ ::.. ,.: 2 - TO WASHED PEAS TONE FREE a-IRONS, ' : FINES AND Qusr IN PLACE ' OPENING W/TH 4�B �4 TO /�2 WASHE4 CRUSNED S70NE. fREIE OF ' OUTER DIAMETER /BONS, FINES AND DUST IN PLACE ANo 1-%4"INSIDE .'. DIAMETER I • ' : I. CONCRETE TO BE 4000 PSI 28 DAYS: 2. REINFORCED Wl' H 611z 611 Willi GA. W.W M \� •'. 1• .3. 21 AND 41 SECTIONS ARE AVAILABLE. BLE FOR 1 1 ...GREATER DEPTH REQUIREMENTS 401, �-- Z -- -----sbN Z --� 4. NUMBER OF PITS REQUIRED o/v�Es MIN. L I n 1 EFFECTIVE D/AMETER -"-1 NOTE; EXCAVATE TO ELEVATION 33.v OR ?Nor To ExcEED 3 rlMEs EFFECr/VE DEPTH) LOWER AS REQUIRED TO REMOVE ALL �----- �•-�--WATER TABLE =- LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TYPICAL PROFILE GRAVEL TO DESIGNED .,GRADE. L.EL�t$o JB"SAO. Lr. WCOr. C./.MN COVER .:: 4 C L PIPE 4'B/T.f%BER P/PE IrAZOW LINE TIGHT JOINT OUTLET LEVEL OWEL L INS TO FIRST JOINT q,DOp 0� 119 O9 1 39. C. TEE ' 43.iy I o 0o 100 i 1 y Q $TO PRECAST CONC. /ST. BOX TO BE3,pp 1 10 08 00 1 1 I I + lMGAL;SEPT/C T /NSTALLFD ON LEV,�.C; ! 11 0 00 00 0 1 I I 1 11.0o0 00 0,1 STABLE d9ASE 111 p 00 1 1 1--- 1 O �SEPT�84 TO BE 1 1 1 A 0 O 00 IN. LEVF�, 1 I 1100100 1 1 t 1 STABLE I I 1 0 0 0 O 0 0 1 1 I ; 111840 0.011 , , ZEACH/NG BASIN op BASE TO,BE L VEL e 0 b 0 0 ! 1 ; , : },, SOIL AND PERC. DATA 370 PERC. RATE G?. MIN. /lN. 0„" TEST PIT NO. t��G33 11 TEST PIT NO. r 0 �. TvP L—)'1�5o L L �. TEST BY: two 4_4 L,V Z. WITNESSED. BY: IFOtJ �Lr>✓oF_t? "'�T I�lEn1L)M IVE TEST PIT GR, EL. DATE: lz ti� ,vrx�aTE�z V o �16z+•t p kraT 1lr_ DES/GN DATA GENERAL NOTES BEDROOMS' NO HEAVT EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL N_ �� SEPTIC 'TANK, DIST., BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL. �GPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK IOeO GAL. A4.L SYS7EM'COMPONENTS SHALL BE INSTALLED IN ACCORDANCE SIDEWALL AREAZ y GAL./SQ.FT. TO'R.EVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, IAINI.MUIM'REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA L GAL./SQ,FT. S� TARY SEWAGE, EFFECTIVE OW JULY 1 , 1977. LEACHING REQUIRED I?9'1 SQ.FT... ,.ANY CH. ANGES -TQ THIS PLAN MUST BE APPROVED BY THE"BOARD ACTUAL LEACHING AREA OFI�,EALTH. Z_�Q.FT. AT.COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE `' '.•BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES I/q' / FT, UNLESS INDICATED OTHERWISE, V V r SE WA " DISPOSAL SYS TE�I o MARTIN yG'o E. 'Q�; Ltt L ram-0 1�1�aw 5 O ;N7 L.o l (2 v M �5 Iz t SCALE AS 1#0I0AW GAr4r �11,� I, �? t 4-- WN. .M. f'o4RWCK 8 ASSOC. /NC, BOX�00/ - NpRTR M T/� r PROFESSIONAL ENGINEER T•, { d a a . LOCATION SEWAGE PERMIT NQ j ®� /off arrMf�S ll�1 ve -Or iW-1. A G E ' INSTALLES N ME b ADDRESS : R' g U I L D E R OR OWN ER DATE PERMIT ISSUED {A DATE C0MPLIANCE I5S '�1ED f a �� 36 t TOWN F BARNSTABLE ff •y` LOCATION SEWAGE # VILLAGE ','ASSESSOR'S MAP& LOT a ' INSTALLER'S NAI H E NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO. OF BEDROOMS NO. , BUILDER OR OWNER , PERMITDATE: COMPLIANCE DATE: 9 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility F Private Water Supply Well and Feet Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) t. Edge of Wetland and Leaching Facility.(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet Af' w 37� 6urnPS Rioe6' i0. Cen e��ille 'TOWN OF BARNSTABLE L ATION %c►wAriw S,,RoA �APs ' SEWAGE #XASP.eC71m/ ` l AGE_ rv,�IC O-. _ - : ASSESSOR'S MAP& LOT f a N INSTALLER'S NAME&PHONE NO. ce tl� �\ i S ^- a -s ,ct SEPTIC TANK CAPACITY F LEACHING FACILITY: (hype) (size) 1100066, NO.OF BEDROOMS BUILDER OR OWNER �ici+ Sr' YI PERMI`DATE: COMPLIANCE DATE: ' /aiv, Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 fef of leachi g facilitY) NA Feet Furnished by /�ir�� � �! 4 AV I 36 ?T at a,ra ?I fi DEPTH TO GROUNDWATER r Depth to groundwater.��feet °A��ollo•h oT SAS hod of determmanoo m avwoainwion: L—c n MIL4 a 1 { i TOWN F BARNS ABLE LOCATION �� S SEWAGE # VILLAGE ASSESSOR'S MAP &LOT Io 0� �j INSTALLER'S NAME HONE Nr0 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: 'off I3 Separation Distance Between the: ' Maximum Adjusted Groundwater Table and 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 1 � �6 is \ 3?`� 6urnPS V�iL)ec ,0. Cen�ec'�i11� 'TOWN OF BARNSTABLE 6 LOCATION '1?k'L*AR0 Sya0n— 37�iJrn�s R"�i SEWAGE # -'r1SPCC-iOA/ V124LAGE ®1S ke-w,&, ASSESSOR'S MAP &LOT f 910`f�` INSTALLER'S NAME&PHONE NO. `7 tv ce.hCLC k V i Sic^— z'-5�� SEPTIC TANK CAPACITY /j 0 0 0o J / LEACHING FACILITY: (type) �� ✓01 7 (size) /0OQ6g/� `- NO.OF BEDROOMS BUILDER OR OWNER S:t tUl PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 feel of Ihiqg facilit lv;19 Feet Furnished by. !� , I Gacacc H o' ay, DEPTH TO GROUNDWATER 'Depth I. Groundwater._s2?Lfeet �7re��olTu,e.o �qS i method of det,--'-,n a aPOra><imation: Z CS:.�•. y, c t\ S ,rw,aw�r tsr sfi 9 LOCATION SEWAGE PERMIT NO. &®"t #ia t� e Adz 9q a- l VILLAGE ' INSTA LLER'S N ME i ADDRESS 41 d UILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE IS,SJED ?5 C 1 z. .p a ..g: . vo , 1�1 36 . tJ t