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HomeMy WebLinkAbout0065 DEERFIELD ROAD - Health 65 Deerfield Road ° Osterville P A = 166 081 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property Address - Cynthia . Kett Owner Otemer's Name information Is required for every Osterville MA 02655 12-6-12 .. . ... ... .. page. Cityfrown 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 filling out computer. A. General Information ,,, �tHOFfhi,4 use only the tab �0��+�� key to move your 1• InspectorJ14 _ r,P � ���: JAMES ,,� cursor-do not = T James D. Sears =�, cr_ use the return. _. L- i ke Name of lnspector y Capewide Enterprises.LLC �t Cornpa..nyName. ��i F R G p�� g I N s?S `���� 153 Commercial Street ��//nrnc„nnti����° Company Address- » Mashpee MA 02649 C,ityrTown — State Zip Code .508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was:performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 1.5.0,00).The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority ram? C7 �- 12-6-12. spector's Signature Date The system inspector shall submit a copy of this inspection report to the Appro ing AuttiQrity(yard of Health or DEP)within 30 days of completing this inspection. If the system IS' shared syster r s has a design flow of 10,000 gpd or greater,the inspector and the system owne shall submit they report to the appropriate regional office of the DER The original should be sen to the system o.>i{ rter and copies sent to the buyer, if applicable, and the approving authority. aw+ r F "**f'This report only describes conditions at the time of inspection and under the conditions of use Olt that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 0V (2) i� t5ins-11110 Tide 1f Inspection Form.Subsurface Sewage Disposal System-Pegg 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett Owner Owner's Name information Es required for every Osterville MA 02655 12-6-12 page. Cityrrown state Zip Code Date of Inspecfron B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® 1 have,not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by .the Board of Health, will pass. Check the box for"yes", "no"or"not determined."(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old`or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. I A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ N ❑ ND(Explain below): ISlns•.11M0 Title 5 OtTdal Inspection Form:Subsurface Sevrage Disposal System-Rage 2 ar 17 Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface.Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property (Cynthia Kett Owner lJwrlef's Name informationis required for every Osterville MA 02655 12-6-12 page. City/Town state Zip Code Dale of Inspection B.:Celrtif catiOp (cost.) 13) System Conditionally Passes(coat.): ❑ 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): El obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): El distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to.protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(7)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh (Sins•11110 - Title 5 Official Inspection Fomr.SUbsWace Sewage Disposal System.Page 3 of 17 zommonw, ealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam- Not for Voluntary Assessments 65 Deerfield Rd. ii;; e y Address Cynthia Kett Owner owner's Name information is Osterville MA 02655 12-6-12 required for every page. cityfTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis rnust be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes. No Backup of sewage into facility or system component due to overloaded or - clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 0 Liquid depth in is less than 6"below invert or available volume is less than"/day flow Wins-11110 - - Title S Otrdal Inspection Ferm:SubsuQepe Sevrage Disposal System-Page 4 of 17 Commonwealth of(Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 65 Deerfield Rd. _ Property Address - Cynthia Kett Owner Owner's Name information is required for every Osterville MA 02655 12-6-12 page, CityrTown State Zip Code hate of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection. Area—IWPA)or a mapped Zone II of a public water supply well if you have answered"yes" to any question in Section E the system is considered a significant threat, or answered"yes" in.Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15111s 71N0, 'Me 5 OMdal rnspedion Form Subsuftoe Sewage Disposed System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property Address_ Cynthia_ Kett Owner Owner's Name intorrrratbn is Ostetyille MA 02655 12-6-12 required for every _. Page, ; ,C ty/Town State Zip Code Date of Inspection Check if the following have been done.You must indicate"yes"or"no"as to each of the following,: Yes No ❑ Pumping information was provided by the owner, occupant,or Board of Health 0 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? a ® 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 we not availablere note as NIA) ® Q Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ®. Q 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 SoR Absorption System(SAS)an the site has been determined based on: ❑ cxisihig 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 appioxinic:uon of distance is unacceptable)[310 CMR 15.302(5)] Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-1 m a Title 5 Offidal Inspectim Fam:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett Owner Owner's Name information for every reqquiui red f Osterville MA 02655 12-6-12 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal Precast tank, D Box and Pit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[it yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes No Seasonal use? ® Yes ❑ No -51 Water meter readings, if available(last 2 years usage(gpd)): 201418,OOOGaIs 2011-08,000Gals Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Na Date CommerciaUllndustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personsfsq.ft.,etc_): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Nan-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: (S ns•i /70 Tits 5 Official Inspection Form:Subsurface Sexepe Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65.Deerfield Rd. Property Address -Cynthia Kett Owner Owner's Name . information is required for every Osterville MA. 02655 12-6-12 page. cityrrown state Zip Code Date of Inspection D. System Information (cont.) Last da.te of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system [] Single cesspool Overflow cesspool Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records,if any) Innovative[Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a ropy of latest inspection of the I/A system by system operator under contract Tight tank.Attach a copy of the DEP approval. Q Other(describe): tslrs-11110 Title 5 ORiclal Inspection Fome Subsurface Sewage olsposal System-Page a or 17 Commonwealth of Massachusetts =mum: Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett Owner ownets Nam e information is required for every ;Osteryille MA 02655 12-6-12 . . page. Crtylruwn State Zip Code Date of Inspection D System lnforimation (cont) Approximate age of all components,date installed (if known)and source of information: Tank and pit 1979 Permit#79-318/ New D Box 12-6-12 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18„ feet Material of construction: ❑cast iron ®40 PVC Q other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage,etc.): Plpeing is 4" PVC SCH 40 Septic Tank(locate on site plan): 10" Depth below grade: feet Material of construction: 10 concrete 0 metal [].fiberglass ❑ polyethylene ❑other(explain). If tank is metal, list age: years '--- Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) [] Yes ❑ No Dimensions: 1000 Gal Precast 1" Sludge depth: tSins-11/10 rode 5 Oftial Inspedlan Fam:Subsu face Sewage Dtsposaf System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett Owner Owner's Name information is I OsteNille required for every MA 02655 12-6-12 page. cityrrown State Zip Code Date of kis pection o. System Information (cone) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 28" Scurn thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance.from bottom of scum to bottom of outlet tee or baffle 18" Now were dimensions determined? Asbuilt-Tape Sludge .fudge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and outlet cover at 10", inlet cover under patio stones, Tank at working level wl in and outlet tees, No sign of leakage or overloading Grease Trap(locate on site plan): Depth below grader Material of construction: 0 concrete ❑metal ❑fiberglass El polyethylene ❑other(explain): Dimensions. Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scam to bottom of outlet tee or baffle Date of last pumping: Date eslns �vio Title 5 Official Inspecoion Form:SUDsiaface Sarrege otspagal system-Page 10 of 1.7 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett owner Owner's Nam_e information is required far every Osteryille MA 02655 12-6-12 page. Gtylrown state Zip Code Date of Inspection .0. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tght 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(expla.n): Dimensions: Capacity: gagons Design Flow: gallons per day Alarm present;. ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 151n9.11M0 Tile 3 Olridd Impecdon Form:Subsurface sewage Disposal system-Page 11 of V Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett Owner owner's Name intormaGon is MA 02655 12$-12 required for every -Osteryllle page. Citylfown State Zip Code Date of Inspection D.,System information (cont.) Distribution Box(if present must be opened)(locate an 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 is 16"x16"-21" below wlone line out, Box is new wt cover at 6"below grade i Pump Chamber(locate on site plan): Pumps In working order fl Yes No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc_): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: mas•ti in o role 5 Olfidd Inspection Form:SW Sewage Dispr 1 System-Page 12 or 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett Owner owner's Name information is required for every Osterville MA 02655 12-6-12 Page, city/Town State Zip Code Date of inspection D. System information (cont.) Type: leaching pits number: 1 I, leaching chambers number: ❑ leaching galleries number: - El leaching trenches number, length: ❑ leaching fields number,dimensions: overflow cesspool number. El innovativetaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leaching is one 6'precast pit, Pit at 2V'below grade w/cover at 1 T Pit is dry and clean walls No sign of over loading, Solid carry over or high stain line Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11110 Tifle 5 Offi ai lnspaMon Fa mr Subsurface Sewage Disposal Syshern-Pape 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property Address ;Cynthia Kett Owner Owner's.Name iM i requiredaired for every Osterville MA 02655 12-6-12 for e page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5nt•1111U TiUe 5 O idd Inspection form:Subwftce Sewage Oispotal System•Page t4 of 1T Commonwealth of Massachusetts Tin Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett Owner Owner's Name informationrequired is Ostervill.e MA 02655 12-6-12 required for every. • page. Cdy/Towri State Zip Cade Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately �!1�r a STo;v f • o I Lfl wN 2 7-- k. v 3 PIT /)- = ,33 - b � . f A-3 YZ ,3_, _3c��c t5ins-11110 Title 5 OkTdd rrtspeuion Fomic Subssudaoe Sewage Disposal Sy tam•Pape 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. Property Address Cynthia Kett Owner Owner's Name information a Ostervilie MA 02655 12-6-12 rtagttit+ed for every _ page. citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ .Surface water ❑ Check cellar ❑ Shallow wells 0 12+ Estimated depth tolhigh ground water. feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record i If checked,date of design plan reviewed: Date i ❑ Observed site(abutting propertylobservation hole within 150 feet of SAS) Q Checked with local Board of Health -explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Lot and area high No G.W.problem seen Before fling this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11110 TOW 5 orgae,tnspeelbn Fort:Subssa(ew Sewage Dhpoeid System•Page 16 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 65 Deerfield Rd. PrWedy Address Cynthia Kett Owner Owners Name information is Ostervitle MA 02655 12-6-12 required for every _ page. cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary. A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5irta• �n o TMe 5 0Mdal Inspection Form:Subsudew Sewage Disposal System•Pape 17 of 17 No. a V f ck— NO Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Misposal 6pstem Cons"ttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.65 DeQx- ,--IJ KA Owner's Name,Address,and Tel No.1�-3 bS crgol��s Assessor's Map/Parcel 10�0 0 �5 (>V&�-;a�dl (� (�s��tV' Installer's Name,Addrp s,and Tel.No. rog ti 77—$$'7-7 Designer's Name,Address,and Tel.No. Cs�„�w�6 v�zx'C�,SQS' pntcis Type of Building: _ Dwelling No.of Bedrooms Lot Size ,A5 A+ sq.€i. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 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) 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. Signed Date Application Approved by i� 1iL'(/ Date l�. Application Disapproved by Date for the following reasons Permit No. ( a' Date Issued ✓ I-?,- No. oZ 6( 'k— 3�0� Fee w d, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS E ftpfication for Disposal ,pstetft Construction j3ermit :t Application for a Permit to Construct( ) Repair( ) Upgrade(, ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ,.e R Owner's Name,Address,and Tel.No. ;?�03 Assessor's Map/Parcel u.,j L*V6T bS rtsko LA-t' c y"` ,- Ke 0 v e v,,11� Installer's Name,Address,and Tel.No. !rQ?• t'77_Yg77 Designer's Name,Address;and Tel.No. Cd.Pew Type of Building: /� Dwelling No.of Bedrooms Lot Size "a5 A. sq_ft. Garbage Grinder( ) s Other Type of Building No.of Persons j Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 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) Pl@ 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 Coo mpliance has been issued by this Board of Health. Signed _ Date K ` Application Approved by Date Application Disapproved by Date \ for the following reasons Permit No. 1 a- Date Issued / h j TIC E COMMONWEALTH OF MASSACHUSETTS .' / BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired_(V� Upgraded( ) s Abandoned'( )by at i,e_U . LPG 1 u c--- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer W I&Q-* Ey►Ter .pr��'-S Designer #bedrooms Approved design flow gpd The issuance of this permit shall--not be construed as a guarantee-that-the system will . action as,designed. Date ( p ! Inspector No. (?( >- Fee c THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Misposal :Fppstem Construction permit Permission is hereby granted to Construct ;( ) Repair(V� Upgrade( ) Abandon( ) System located at �"� QQn -� b e 1 al �d (j ar V" e and as described in the above Application for Dispos dystem Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date O(� ��-/�� Approved by ✓tit. COMMONWEALTH OF MASSACHUSETTS { EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 4 d d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEI 5�a MAY 1 2005 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 65 Deerfield Road (Osterville)Barnstable,MA (�(„ Owner's Name: Anthony Franchi,Jr �> Owner's Address: 7 Wolfaen Ln � Southborough,MA 01772 Date of Inspection:Aril 26,2005 Name of Inspector: Gary J and/or Jane E Rabesa Company Name: Rabesa Subsurface,Inc dba Warren Cesspool Service Mailing Address:PO Box 2302 Teaticket,MA 02536-2302 Telephone Number: 508-540-7143 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes j Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature Date: May 11,2005 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments:Title V system with no failure criteria. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi.Jr Date of Inspection: April 26,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: YES X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: NO One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: k Warren Cesspool Service 508-540-7143 T;.ia c 1—,. +;—V,....,,All ci')nnn 2 f Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi,Jr Date of Inspection: April 26,2005 C. Further Evaluation is Required by the Board of Health: NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment- Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Warren Cesspool Service 508-540-7143 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi,Jr Date of Inspection: April 26,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy.is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Warren Cesspool Service 508-540-7143 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi,Jr Date of Inspection:April 26,2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x — Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? x _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) x Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x_ Were all system components,including the SAS,located on site? x_ 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? x _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no x Existing information.For example,a plan at the Board of Health.. x _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. Warren Cesspool Service 508-540-7143 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi,Jr Date of Inspection:April 26,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):three Number of bedrooms(actual):three DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 gpd(425 provided) Number of current residents: none(previously four) Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no[if yes separate inspection required] Laundry system inspected(yes or no): n/a Seasonal use:(yes or no):yes Water meter readings,if available(last 2 years usage(gpd)):2003 averaged 58 gpd,2004 averaged 38 gpd Sump pump(yes or no): no Last date of occupancy: last summer. COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:(owner)no record of pumping. Was system pumped as part of the inspection(yes or no):yes If yes,volume pumped: 1000 gallons--How was quantity pumped determined?Tank size Reason for pumping: maintenance TYPE OF SYSTEM x Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy _no_Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1979 permit on file. Were sewage odors detected when arriving at the site(yes or no): no Warren Cesspool Service 508-540-7143 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi,Jr Date of Inspection: April 26,2005 BUILDING SEWER: (locate on site plan) Depth below grade: 18" Materials of construction: cast iron x 40 PVC other(explain): Distance from private water supply well or suction line: town water line 26'. Comments(on condition of joints,venting,evidence of leakage,etc.): f SEPTIC TANK: X(locate on site plan) Depth below grade:9" Material of construction: x concrete_metal fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: standard 1000 zallon septic tank with concrete tees Sludge depth: 16" Distance from top of sludge to bottom of outlet tee or baffle: 18" Scum thickness: none Distance from top of scum to top of outlet tee or baffle: ------------ Distance from bottom of scum to bottom of outlet tee or baffle:------------- How were dimensions determined:onsite Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):The tank has no failure criteria. The DEP recommends pumping every three years,depending on use. The tank was pumped at time of inspection. GREASE TRAP: NO(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene_other (explain): — — — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Warren Cesspool Service 508-540-7143 Page 8 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi,Jr Date of Inspection: April 26,2005 TIGHT or HOLDING TANK: NO(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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: YES(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Viewed by remote camera,no failure criteria noted. The cover is 18"below rg ade• PUMP CHAMBER: NO(locate on site plan) Pumps in working order(yes or no):------- Alarms in working order(yes or no):-------- Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Warren Cesspool Service .508-540-7143 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi,Jr Date of Inspection: April 26,2005 SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required) If SAS not located explain why: Type x leaching pits,number: one leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The 6' by 6' precast leach pit(with one foot of stone per engineered plan)was dry at time of observation. Signs of staining are no higher than 40"above the bottom. The cover is 9"below grade over 16" riser. CESSPOOLS:NO(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer:_ Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): no Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: NO(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.): Warren Cesspool Service 508-540-7143 Page<10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 Deerfield Road (Osterville)Barnstable,MA Owner: Anthony Franchi,Jr Date of Inspection: April 26,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM NOT TO SCALE Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. . CAI RFArZ- g bruc. ; O S E PTI C' TAly ` C.Etc;N� =p►T- Warren CesApool Service 508-540-7143 Tit1n i Tn wni.*inn'L'nrm(.!1 Q/')IAnA 10 e Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:65 Deerfield Road (Ostervillel Barnstable,MA Owner: Anthony Franchl,Jr Date of Inspection: April 26,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM NOT TO SCALE Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. REAM � o- O N SEPric. TAN Warren Cesspool Service 508-540-7143 r - t T;+1.C Tn „onl:Awir'^w A/1 VI)nAA 10 LOCATION SEWAGE PERMIT 00. 'Jo VILLAGE X r���1/L INST L EA'S NAME A A D D 0 E S S B U I L D E R OR OWN DATE PERMIT ISSUED DATE COMPLIANCE ISSUED C - Aa i r ''e 1 � n` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................O F... 6F ------................................ Appliratio a for %gvoii al Works C onjotrurtion Wruti# Application is hereby made for a Permit to Co suct ( ) or Repair ( ) an Individual Sewage Disposal System at: ,'` .........V /. ........................... _............ /... .........................................................-Location-Address or Lot N . ............ �.�... .... r��C14----------- ------------------ �_...... ........W.e.._ F .�..il ss Owner Address W ............ d._.... - e----- ...:.....-•--•...-----•-----•---------•----------=-- ............................................................. Installer Address PQ Type of Building.- Size Lot............................Sq. f t U DwellinNo. of Bedrooms---.._ _ .--..Expansion Attic ( ) Garbage Grinder 6 ._______________________ Other—T e of `ildin No. of persons............................ Showers — Cafeteria d Other fi res .. = W Design Flow.......... .............................gallons per perso �r c�ay. Total d,4ly tow.........- _. ,.. __. .........._..._gallon a.�. WSeptic Tank—Liquid capacity C�?t?gallons Length - -4------ Width.�:_.1.�..... Diameter-. -- .... Depth.4-:-4 x Disposal Trench—No. .................... Width...... `.......... Total Length.............'_..... Total leaching area....................sq. ft: Seepage Pit No......I_........... Diameter..........Y----- Depth below inlet.... ........... ft. Z Other Distribution box ( ) Dosing tank ( ) e a Percolation Test Results Performed by-----/4_e-....jo 4,?.t�........................ � :_---:-/._._...._._. Date . ..� 7 a Test Pit No. 1.4..�__._minutes per inch Depth of Test Pit..... :_...__ Depth to ground water.DUtie� ��.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................--.. a .........:............................................•-•--....••--------...... ------------- O - Descriptionof Soil •4 ow-----5f- ...---------------------------------------------------------------•-- .............................. ...... W -------•-------------------------•-•••-•-•------••--•--------------••---•---••----•---••---•------••-----•-•---•--------...------------•---•--•----•-------•------•-••--•---•----------------..---•- VNature of Repairs or Alterations—Answer when applicable.-------------------------------------------------------------------------- --.--.------------.--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT= 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed-•-all .. ? --....).141.------------• 4 Date Application Approved B �L PP PP y------....� Date Application Disapproved for the following reasons---- -------------------------------------------------------------------------------------------------------•---- ..................•----------------•........-••---....---•--••--------....---------------------••-••.......--------------•--.......----•------------•-••-•--•-----••------•----------------•---------•--- Date Permit No..........31_.7........=......................... Issued-...EL 3/L 7 Date ��� ��xux»w THE COMMONWEALTH OF MASSACHUSETTS BOARD,,OF HEALTH ��� °� ��@�����r4�tmmu� ��� � l Worka Tanwtr44r4iou» amot Application is hereby made for u Permit to Construct ( ) or Repair ( ) an Individual S - .Disposal System at: -_--'-------------'------------ = c�t No ---' ~. ~ -----------------' ..................................................... ��_-'---'___'------'---' � Owner ----'-�-------'r----'--------------------'---'-'--- '--------'--------------'------------------'----- ' z=*x= Address � Type of Building,- Size Dwelling�r--No. of Bedrooma--'A..�.............................Expansion Attic ( ) Garbage Grinder /1b Other—Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) Other fixtures `- ' ' - ' ' .----' --- .- Design Flow.......... ....gallons per person.per day. Total daily �ow......... Z Other Distribution box ( ) Dosing ~~ Percolation Test Results Performed bv...." ^Ae!V.1�5n......................................... D� -- �-_-c ��'�-��-�-� ' , -� Test Pit No. l��''��.-m�uz�sper�ch Depth of Testd- ��� ---� ' '' Depth to ground wotcc4���~./Ze- [TA Test Pit No. 2................minutes yor inch Depth of Test Pit.................... Depth to ground wztcr.----'----.. '- .--_- - Description of ovu-.-. ..... ;e==�............................................................................................................... � ------'---------'--'---------------`---`-------------------------------------'----- .--------_.__---'-.------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations--Answer when .----._--'-_.`-_.-_-_----_-.-__'--.. | -----------'-----'-'--''-'-------------'--------------------'----'-'----'----------'- � Agreement: � � The undersigned agrees to install the uforo8cscribcd Individual Sewage Disposal System io accordance with � � the provisions of TAlIiE 5 of the State Sanitary Code— The undersigned further agrees not noo�e8e ��m � � ' � operation no6l u Certificate of Compliance has been issued by the board of health. � Signed...................................................................................... ................................ � . Date 8ppbcutuooApproveduy_'_-� ............................................., ____--__'___'__' ........................................ JI ��,t+JtaL� �t�nnt��l - 3 �sirver�caM - I vG ij — •, Latt_�{ �Lvw = tra 3 = 33p G.P.D. - � IC TA,,1K A-9PV 6.P.0. USA 1b00 GAI-. M.w Q 9� .acl ,f Icy c� ,e 2.S' = 1S (5;, 10, Q -o c1 a2FFv _ sr-. 46 n' Nd`� r^►,<'M TOTt-L- T'�ESl6Kl = 425 2° z T-oT41 r_ -CI-4-r�'-f r LAD��i = � 33� 6�. 6 PSVC- >L&T1 lLJ VkeTE Cto 2Mtu* orz L.". 1 \ h-y Id rry� WtLt,IAM NrEST .. NF to, 19334 -reTor F.+o s ioo.o sT 97, 00 e �~ I oao iuv. •H svaso Z 4'PP� aft 1w. 9Gt• -Sox Seprtc V. o) TA�tK LEAca e PlT MGDl UM W�Tt•d •� SA WLtS►IET] STOWS= gq,� P -- - iL L0C.A.TIo)-1 06TC--IZ- .� E at1•=v> ta' ► to SGAL� G Lt-- )"= 40' rATir 5/Z 1/7q N p WATE 2• ' PRO pos sn pt, t�.t�i 2i_i= �EF.c6.ILa I c►,r<Tt4=�� TWAI- TNT F'OUNVNTION► Staow►J --- 11�_I.'r=t5�.1 Ct;.tiN.VLI(S Vl/ rTN Tr-li= �jIDE LI►-IE: LOT d� Ar.Iz� ';i�'rl'.hCl; �'C-LJJ� Mi.►..tTy of T"(Z. ! -To vi L? C F: L.C. ala -73 ? I� IZEGIS rZ(Z�.i� LAND iU�Zv�Yut=� I Tt-115 t7 t_Ae-I 1', a-1C�T L' A�,Ci7 Ut 4 1-' " USTEV-VkL-LG c) /VCAsi• s� ;W�,I':?.J.=✓lr=k,,4 '�t�. /t._11' �t�r_: c:Ft=�r(-, ���1[:e1t� A.NI'L-iC TDNY N CH ) �' t ' .(" �•,r'. U ,i_r �1 i">t-.1'i.►��1r1►�11: �O"C t-►N`=`' _ _ _—__. --' _ � ��_ _ -- i aAr LOCATION SEVAGE PERMIT NO. VILLAGE IN T L ER'S NAME i ADDRESS" BUILDER On OWN � 9 DATE PERRL�T ISSUED DAT E COMPLIANCE ISSUED q x q ,toy a �'