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HomeMy WebLinkAbout0099 EAST BAY ROAD - Health 99 East Bay Road 'p Osterville_ P A = 140 162 a L� i I t - o III C�) p_ 1 tt t C b `f 0 ' Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd Back yard '' Property Address h y David Brajczewski Owner Owner's Name information is �/ ?= required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection f, Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information �S% 3y�S filling out forms on the computer, Michael DiBuono use only the tab key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name keY• 35 Content Lane ,Q Company Address Cotuit Ma 02635 Cityrrown State Zip Code 508-364-9587 S113522 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 10/24/18 Inspector's 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form w �- a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1000 Gallon septic tank as well as a concrete distribution box and a 4'x6' Leach pit. There are no signs of failure at this time. 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 1. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t; 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval,if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are,replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 coo, Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® 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. ❑ ® 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 a ❑ ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form t. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v � 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 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 ❑ E 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)] I t5insp.doc•rev.7/2 612 01 8 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 99 East Bay Rd Back yard �V Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 ; Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 118 GPD 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Cityrrown 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/user Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd Back yard v Property Address David Brajczewski Owner Owner's Name information is required for every Osteryille Ma 02655 10/24/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,�attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 4/21/93 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented through the roof t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 Gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4° Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee's in place t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Cityrrown 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 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ 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 Level and at normal level 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osteryille Ma 02655 10/24/18 page. Cityrrown 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 x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of failure. 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 to Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is Osterville Ma 02655 10/24/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14, Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 px If Awl y ,�1�5 sr r ,� a qs•F'<, g .x4 4 ��,� �� �=� � �,SP� ,r� � � �M�� ��'� QR��Q:x U1�TAI2X ASS SSa.• � � S �a �. " WAiC DI SAi ��j \ `���V �� SY�STE a. /�'S` EfiC�H�®F� L'VYd►�GEaD13POSAL�S1' Ci�lY1:= � : � 'EN,OT:TU��S„��1�l �. �` ��� ..Cs'�l l � ."b�,�1 �$' sr. �m� r 9• �!r!/iy.a..k.�`z1,.-; -::'� cy/ 7 +,,� .- .� � (:.. a,^• Sa"a:::i,.a,a.. 4 ;, a -:r..y.>.,' Prouk>d�e;�a�'slc�et�h ��.t�.:�:b ��>a,,���;�,F� P - �' ,� � d ng x��s�o ,��t"��•. 3 � t ��"�,r�, � , �� r, ���� y€ Ilk taen�chmarks �, ocate all��we€l�s �itla:n OQ feet'�'L � e�►%her�e publ=c watersupp�y entets��the•butidiin . �" ��� ��� �� a � �"f avrt° IMP Im � ,d a, ih. .r• w s x�. T . e �� � �,€�/1l► ,� a �' ,. y i i #!air � � ♦'. fir' � f - � e r rr a a r a Y , NS C1IC) , RM NQ�'FQR �E I�1{N+ ASSS {MAN 5 a. 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(,;�, \ € € '�EeE=����i��Eit �s(3� Y ,-4 ���rtt�E�it� � � ��aE �E >i� ; y�r :K•� ,f,,��". ��� �'<,• "'� d�rYg a?£%�r'tig��+'�a�` :C I�K�W'�t•n � t�'��Tx:�aS�<)���"a>'g��E'���g g� E r '�.. g�Y s t a "� :a,.; ';,3;�t,� .<�l .� . ,,h -t a•Y s9 q'�f S i 4� „d i E �P EJ f[E CE.. ,�9 ?�F f ax �'Eve � "3 '.��"f ag "+ �}€w�s,a,'a a � i � a• �»"�`�> 6 'gh�n E�1��iY5�s K,,a t z ,3s - �+ �P�,� z A, � � 9 ✓ n c a .�� � - Yk � 4y.,.s4- "� � F �i�s�j'�X ✓ � �a." � �. � �F� '� � � zfiY� t t T sa � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 99 East Bay Rd Back yard €.. u Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town r e State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar �' ❑ Shallow wells NGE at 180" 4, Estimated depth to high ground water: feet 'Please indicate all methods used to determine the high groundwater elevation: ®; Obtained from system design plans on record 1 If checked, date of design plan reviewed: 7/30/84 ' Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: s ,.-.You must describe how you established the high ground water elevation:. Test hole data on plan , 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 r - • cam, Commonwealth of Massachusetts I,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 99 East Bay Rd Back yard Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 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 ❑ C. 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 For 15: Explanation of estimated depth to high groundwater included v t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 00- 1 (0a— Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =' 99 East Bay Rd front yard systemCIO Property Address h David Brajczewski Owner Owner's Name information is w required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection rXj 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 forms A. Inspector Information on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 S113522 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 10/24/18 nspector's 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 .., 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is Osterville Ma 02655 10/24/18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1000 Gallon septic tank as well as a 4'x6' Leach pit. There are no signs of failure at this time. 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. i 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 99 East Bay Rd front yard system �V Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments emu, 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is re Osterville Ma 02655 - 10/24/18 required for very q o every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form M1lo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) I 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)] l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number f current r Vacant u o cu e t residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 118 GPD 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date l5insp.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 99 East Bay Rd front yard system u Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.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 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd front yard system �V Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Original to home Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: - 4 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented through the roof t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is Osterville Ma 02655 10/24/18 required for every page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 3.5 P 9 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 Gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete baffles in place. Tank is at normal level t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd front yard system mot,, Property Address David Brajczewski Owner Owner's Name information is required for every Osteryille Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i 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.): i 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 S Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ 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 NA 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is Osterville Ma 02655 10/24/18 required for every 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v% 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Citylrown 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.): No sign of failure. 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form 2 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd front yard system Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Cityrrown 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.): i l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 99 East Bay Rd front yard system V Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. Cityfrown 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 t5insp.doc•rev.7/2 612 01 8 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 % a .� 99 East Bay Rd front yard system u Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town 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: NGE at 180" 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: 7/30/84 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 East Bay Rd front yard system u� Property Address David Brajczewski Owner Owner's Name information is required for every Osterville Ma 02655 10/24/18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 REC'FIV =i--,, COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI S AUG 8 j 2002 d DEPARTMENT OF ENVIRONMENTAL PROTEC ONWN OF � BAFI, �< f EAI.Th -- t V� ~ .TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 'CERTIFICATION Nqp - 1 4 b Property Addr�ss: 99 East Bay Road ?ARCEL r... Osterville.Barnstable,MA LOT Owner's Name: Lisa Hangerty Owneri Address:99 East Bay Rd Osterville,MA 02655 Date of Inspection:July 8.2002 Name of Inspector: Gary J and/or Jane E Rabesa w Company Name: Warren Cesspool Service Mailings Address:72 Sandwich Rd East Falmouth,MA 02536-5602 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature Date:July 15,2002 I 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: Two systems in working condition. Front leach pit is H-10 and should not be parked on. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. f Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:99 East Bay Road Osterville,Barnstable.MA Owner; Lisa HaQeerty Date of Inspection:July 8,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: YES X IIhave not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: There are two systems. The front has a septic tank and leachpit with no distribution box for four bedrooms,laundry and kitchen with garbage disposal. The rear system has a Title V system for two bedrooms. 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 exfiltratiop 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: Warren Cesspool Service 508-540-7143 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION(continued) Property Address: 99 East Bay Road Osterville,Barnstable,MA Owner: Lisa Hai! rty Date of Inspection:July 8.2002 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 508-54077143 T41. c r-o,..:,.., c..-r/I cnnnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 99 East Bay Road Osterville,Barnstable,MA Owner: Lisa Haggerty Date of Inspection:July 8,2002 I 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_ Apy 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 the 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 gad to 15,000 gad. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Warren Cesspool Service 508-540-7143 4 Page 5 of I 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 99 East Bay Road Osterville, Barnstable,MA Owner: Lisa Haeeerty Date of Inspection:July 8,2002 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 rx 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,excluding 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.. i 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)]. *One pit viewed by remote camera. Warren Cesspool Service 508-540-7143 Page 6 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION I - Property Address:99 East Bay Road Osterville,Barnstable,MA Owner: Lisa Hap-aerty Date of Inspection:July 8,2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/d Number of bedrooms(actual):6(4 in front&2 in back) DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): n/d Number of current residents: four Does residence have a garbage grinder(yes or no):yes Is laundry on a separate sewage system(yes or no): no,on front system[if yes separate inspection required] Laundry system inspected(yes or no): n/a Seasonal use:(yes or no): no Water meter readings,if available(last 2 years usage(gpd)):2000 averaged 280 gpd,2001 averaged 227 gpd Sump pump(yes or no): no Last date of occupancy:occupied 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: 4owner)has not been pumped. Was system pumped as part of the inspection(yes or no): no,pumped after inspection for maintenance. If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM x Septic tank,distribution box,soil absorption system Single cesspool —Overflow cesspool i _�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: from previous report, front system is 20+/-years and rear system is from 1993. Were sewage odors detected when arriving at the site(yes or no): no Warren Cesspool Service 508-540-7143 r 6 w Page 7 of 11 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 99 East Bay Road Osterville,Barnstable,MA Owner: Lisa Haeeerty Date of Inspection:July 8,2002 BUILDING SEWER(locate on site plan)TWO Depth below grade:6" front, 14" back Materials of construction: front cast iron back 40 PVC_other(explain): Distance from private water supply well or suction line: town water line Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: TWO(locate on site plan) Depth below grade: front 48",rear 5-7" 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 4000 gallon tank on both Sludge depth: 10"/8" Distance from top of sludge to bottom of outlet tee or baffle:23"/26" Scum thickness:3"/none Distance from top of scum to top of outlet tee or baffle: 811/------ Distance from bottom of scum to bottom of outlet tee or baffle: 15"/-------- 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.):Tanks appear to be in good structural condition with no failure criteria. Both tanks were pumped for overdue maintenance. The front tank should be pumped annually and the rear tank should be pumped every three years,depending on use. 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.): a Warren Cesspool Service 508-540-7143 7 r h i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 99 East Bay Road Osterville,Barnstable,MA Owner: Lisa Haggerty Date of Inspection:July 8,2002 TIGHT or HOLDING TANK: NO(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: I 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: none 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,the d-box for the rear system was in good condition with no failure criteria. The cover is about 16"below grade. The front system does not have a distlution box. 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.): P 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: 99 East Bay Road Osterville, Barnstable,MA Owner: Lisa Hazaerty Date of Inspection: July 8,2002 SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required) If SAS not located explain why: Type x leaching pits,number:2(one on each system) 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 front leach pit is 6' by 6' precast but is not rated for driveways. One foot of volume was available at time of observation. The cover is 15"below grade. The rear leach pit is 6' by 6' and had only 6"of liquid. The cover is 26"below grade. 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.): f PRIVY: NO(locate on site plan) Materials of construction: Dimensions: Depth of solids: I Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): k Warren Cesspool Service 508-540-7143 i T;«io c r-o..«;,,., F,....,,411 ci)nnn 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 99 East Bay Road Osterville,Barnstable,MA Owner: Lisa Haaeerty Date of Inspection:July 8,2002 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. I �ront fQ1t1� � I Warren Cesspool Service 508-540-7143 I raio c i....,o .:.., ❑,...,, i ci�nnn 10 Page 11 of 11 I t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 99 East Bay Road Osterville, Barnstable,MA Owner: Lisa Haggerty Date of Inspection:July 8,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water is greater than 12 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design Ian n r - y g plans o record If checked,date of design plan reviewed: x Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: records on file Checked with local excavators,installers-(attach documentation) x Accessed USG database-explain: town topography maps, USGS survey maps You must describe how you established the high ground water elevation: From area topography,#106 East Bay Rd. is a lower elevation than the septic systems on this property. I Warren Cesspool Service 508-540-7143 � I vv,thin OOeet I,oca;a where pub:li�e water sup=l enters th u�Elclin IWT VPI� I Olf'. 4ll f �4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTIO ' ONE WINTER STREET, BOSTON MA 02108 (61ki 1k 7) 292-5500 /ra WILLIAM F.WELD Pip TRUDY CORE Governor ly2G� Secretary ARGEO PAUL CELLUCCI y9; D� B. STRUHS Lt. Governor gel, "Wbr+missioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �cT b2 CERTIFICATION � Property Address: qq J i 6zxt,Lv:k�4_ Address of Owner: !DQ— %A" Ste. Date of Inspection: S3kyk111p OZ65S_ (If different) ` Name of Inspector: M tr•a,_t U � (� I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: rj 8L_ Mailing Address: Telephone Number: -2— 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: 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. 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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. (remised 04/25/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM + PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BJ 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTION-ING IN A • MANNER WIUCH 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for colifotm 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: 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. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System. cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water'supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet-but greater than 50 feet from a private water 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: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System)'and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) 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 04/25/9'n Page 3 or los SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART B CHECKLIST Property Address: Owner: 5 Date of Inspection: ��`�� Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or 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 �c during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. — The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. — All system components. excluding the Soil Absorption System, have been located on the site. X — The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. A — Existing information. Ex. Plan at B.O.H. — Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04125/97) P2ge 4 of 10 I i. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Cj 0�cu- Owner: 5c 4 Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: s(� G.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:__.I Garbage grinder (yes or no):__4 Laundry connected to system (yes or no): Seasonal use (yes or no): IJ Water meter readings, if available (last two (2) year usage (gpd): IJ Sump Pump (yes or no): 1J Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ allons/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: GE\'ERAL INTFOR.MATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: Gallons Reason for pumping: TYPE OF SYSTEM oZ 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: V ANT- c�c lS�GiM Sewage odors detected when arriving at the site: (yes or no) N� (revised 04/25197) Page 5 of 10 Y A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 91 �Qls:r Owner: Date of Inspec on: b BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _ 40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:S `= (locate on site plan) Depth below grade:±!1�'� �'Z'-,)-4" Material of construction: _&concrete _metal _Fiberglass _Polyethylene —other(explain) to of Compliance (Yes/No) age confirmed b Certificate p list are Is y If tank is metal _ t- — Dimensions: � Dime WQ &I Sludge depth: ' -o" Distance from top of sludge to bottom of outlet tee or baffle: 1 ;3 ' Scum thickness:' Distance from top of scum to top of outlet tee or baffle: �,'W Distance from bottom of scum to bottom of outlet tee or baffle:°'1-i1a't 2.-1A" How dimensions were determined: (NLpttr�C Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, tructural integrity, evidence of leakage, etc.) GREASE TRAP: (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: (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 04/25/97) Page 6 of 10 SLIESURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert% Address: GG iqf( gctll OHner: cT Date of Inspe ion:rp TIGHT OR HOLDING TANK: 8�)7ank must be pumped prior to, or at.time. of inspection: (locate on site plan, Depth below grade. Material of construction _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capac:t`• gallons Design floN galiorsrda. Alarm level A:a1m in .;ork:ng orde• _ Yes. _ No Date of previous pumping I Comments (condition of inlet tee. condition o- ala•rr. and float switches. etc.( DISTRIBUTION BOK:-AuS a ^Box`S (locate on site p an De::h o;houid le.e' aoo.e out:e: n.e� Comments T note level and d,strib—or s eaua' e.•,dence of solids carryover, evidence of leakage into or out of box. e:c.l 00 ter. IL csa. PUMP CHAMBER:_{ (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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prop" Addr-ss: Owner: ' , Date of Inspection:CAVA SOIL ABSORPTION SYSTEM (SAS):—�4S (locate on s'te.plan. if possible. exca%ation not required. but may be approximated by non-intrusive methodst If not determined to be present, explain. Type. leaching pits. number. leaching chambers, number:_ leaching galleries, number. leaching trenches. number.length: leaching fields, number, d,mensior.: overflow cesspool, number Alternative system name of Tecnnoio v g Comments !note condition of soli, s!gr.s of hydraulic failure, leve' of pondrng. co 11 ao of vegetation. etc.' A! - �- Ic CESSPOOLS: VU (locate on site plan Numbe, and coning-jra:,on Depth-top of liquid to inlet Inver, Depth of solids lave- Depth of scum layer Dimensions of cesspool Materials of eonstruaooe Indication of groundwate- ` inflow tcesspool must De pumpeC as par, of inspectioni Comments: (note condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.) PRIVY:_e.0 (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.): lr•vas•G 04/25/91) Page a of 10 I » /„ • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S",S Qy�� �C�t VSTC1Lwv �l.rZ Owner: ;So, Date of Inspection: L ox SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) \/ g2.- 40' dy- ss` C\C\ c 16 R3- 3'1 � Ay_ wd �} L\ I (revised O4/25/97) Page 9 of 10 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: i Depth to Groundwater tiS Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) UtS= .w\TC ���vc:� � �eyiL S►Jv t�.�iPt�cx�c, r-4.r�. b�tL ��� (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE .�` .:. .T Ii3i1 SEWAGE ASSESSOR'S MAP & LOT VAO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY o`� VOC,(ZD!�WN-A LEACHING FACILITY: (type) � (size) OOP �aQC NO.OF BEDROOMS _ BUILDER OR OWNER PATE:_ a I`-i t COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S 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 533T.Cwt 2 -TOWN OF BARNSTABLE LOCATION- � 13.4 ' �/Z'aX SEWAGE # "-/•7 VILLAGE rZl�> ( _ ASSESSCR'S -LOT INSTALLER'S NAME & PHONE NO. /'�2c �+� �•� - S-l� 731i-3 �_' SEPTIC TANK CAPACITY ,�/� LEACHING FACILITY:(tVpe) ?Ra CR,rT /�i % (size)• NO: OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 4 BUILDER OR OWNER az/ Jar r� r DATE PERMIT ISSUED:_ / �- DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No r �I t i No....�� �.1.7� Fzs.......LQ.,C��.......... THE COMMONWEALTH OF MASSACHUSETTS n_rnsr8 gppRp BOARD OF HEALTH �J bye Cogseryat�ipq p 8 TOWN OF BARNSTABLE �nmertr Altrttti>ai<t fnrifittl Wvrki3 Cnngt �rr# s, pr�ti# Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: f ZS AT AvY Z� � vl ....---- ••--•-..._•--••••.......................�...•----••---•------•--._..._....._..... ......---------- •-- • .._..-•-...--•--•.. .....••-- Location-Address or Lot No. /J oe ner Address Ow Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ). aOther—Type of Building ____________________________ No. of persons----_-.-_--__-_____--_--.-. Showers ( ) — Cafeteria ( ) 04 Other fixtures ..................... ------•-•--••-------------------- W Design Flow............................................gallons per person per day. Total daily flow..._...._._.____._____._._.__.____._____-___gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth................ Disposal Trench--No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -..-------••--------•--•----•--------•------•-----------••----••-••.----•-•-•••-••-••......••-•-----•.................••-•..__.........._._................-- 0 Description of Soil........................................................................................................................................................................ x V W ................................................................................................... ------- - U Nature of Repajrs or�Alterations—Answer when applicable._��.x_.._:::_..!_ d .sl__-.-_-_°`.._ �J.... j '0.0... !.b. '.•-t s Y `"� ------ �ref ®o Qa ..`'.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of"TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ue b the ealth. Signe /'' ® ............. °2 a/:� F.. .- .... Date Application Approved By ...............�.e,, ..--.----_V......--.......... --.. . ..... ..... ..--...-- ... ......... .:.-I2..-: Application Disapproved for the following reasons: ...... ..... ..................................... ..... ............................... ..................... ....... ....................................................................................... ............................................................................------------------------------------------------------- ........................................ Date PermitNo. ..........�3--------j... -- .................d Issued ..................................................................... Dare `y,/�.-....�d�v'-vv+y`-.+..��_-�.r-•-,J..`......`...�,r....-....-..�-L-v-...-�'ti"�-..--,r.�4.v�f'"a.r--.-..��,.,� -.v- ......�+-. v... ...._-�rV�„ ,y ..o _ - .F .. No....,2'3•---Z Fzs....- .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE /f Appliration fur Diripw3al Nurlta, Tomitrart- -ti Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: r 5 /3 l2 'fi 2 �/ // •..... ---- . `-'•-s r /3/-7 -----------....... - J�` Location-Address or Lot No. ............................... G---------•----•--•-----••--•-••-- ------------------•------•---.....----•--------•-•--------•-.•----•....................._..... owner Address Installer Address UType of Building Size Lot............................Sq. feet t..t Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.-._-..._-.._.__._-_---.._. Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------•----.._..--------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length--.------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width............._...... Total Length........_........... Total leaching area....................sq. ft. . Seepage Pit No----------------_-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test pi o. t N I suits minutes es per inch Depth of Test Pit.................... Depth to ground water........................ Gi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ---------------•--------.....----------------------------•-•--------•-----------••--•---=----..........-•-----......_........-•-----•-•...__......_----.. x ..-. Description of Soil---------------•-----...----•---•-------•--••-----------•--------•-----••------•--------•--------------------....--------------•---•-•--•------------••••-•-----....._.. x ...................................................................................................................... ................................................................................ U Nature of Repairs or Alterations Answer when applicable...'°)*"-.....-(-Ut?0_.S :______''`"__("/)-._4L?(oG o -•-•---•-/-..•�-'le----�-_•/ v caa •-..------ 1 a e?r...L�--•-•....................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the a system in operation until a Certificate of Compliance has been issue y the board of'-h th. � -`- • Signed ��.-'r.,�--�...................._......... ��A7�/ �'�..�... ....._.. ............................._ �, Dace ....�....... �y Application Approved By ................ .....�...... .......` . ............................................. l . ... � ....... �. Application Disapproved for the following reafon.r: ............................. .... .. .. ...............-- ...:............. .. ............... ..................... . ............................................ .. ........................................................... ............... . ............... .......................... .... ........................................ Date PermitNo. ...........7.._)-- l y a�---------------- Issued ............................................................... Dace L THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Ex#ifi ate of Tomplittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ............................. !_i? H --------- -- ---------------------------- -------.......-------------.............--------------------------......-----..._------------------------------------------ at ............... ... ........... .. .5�.........lJ�r3_Y �2c' ... �.�r..l.......... -- .............. has been installed in accordance with the provisions of TITLE 5 of The State Environmental ......Code as described in the application for Disposal Works Construction Permit No- ._- ..... dated ......................._...........__.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....................- ...'... -.. ------.L....�>........ ................................... ............... _ Inspector C.� --=— —_--- -- --------- �---- ———— ——————— — —Q` THE COMMONWEALTH OF MASSACHUSETTS t% BOARD OF HEALTH TOWN OF BARNSTABLE / No...... -.^._ . g I'EE......... .... Dispaaoul orkaa Tonstrud aan Wrn it Permission is hereby granted............. --�--------•-----•---•••..............•••-----.._._..------•--.......----•---••-•---•-•--...._...._........ to Construct ( ) or Repair (4•)an Individual Sewage isposal System street as shown on the application for Disposal Works Construction Permit No 7.1-n- — Dated.......................................... .............................. S .: ............................................................. t: _r� t Board of Health DATE.............../-._._..... - - FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS f 362.4541 926 main street yarmouth mass. 02675 down cape eafiaeering civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys site planning sewage system designs June 28, 1985 inspections Barnstable Board of Health Barnstable Town Hall South Street permits Hyannis, MA 02601 On June 25, 1985, Down Cape Engineering inspected the sewage system construction of Lot 88 Cobblestone Road in Barnstable and found the system to be con- structed as shown on the .attached "as built" plan and conforms to the intent -o.f the design of July 30, 1984 and revision on November 20, 1984. Sincerely W, Arne H. O,j ala President WES/kmk Enc. Fx�..c ..!] ........._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Z _ w. oF.......... . . . . '.. �. .�or .�;�.-. �-------------------------- Application is hereby made for a Permit to Construct or Repair ( } anZ�ldividual Sewage Disposal N..bt ystem at: / ) T-�.9 4 0. ...........:^_. � f�f o at n-.Addr.e C`l �Q �- �//�r/il� f....................or. Lot No... Owner •Address a .......... ...... .................................... ............................................................•-................................... Installer Address U Type of Building Size Lot....,��,.✓��6...$q. feet Dwelling—No. of Bedrooms...... ...........................Expansion Attic ( ) Garbage Grinder ( ) `C1414 Other—Type of Building ....... No. of persons.....................: Showers Cafeteria a Other fixtures ----------------------------------------------------- W Design Flow.....J.^A...:..... ..gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid ca7aofr ��.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No............... ' Width.................... Total Length.................... Total leaching area....................sq. ft. � Seepage Pit No P114_ .�L"Dla ete"r.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution bcd( ) Dosing tank ( ) Percolation Test Results Performed by.................................................•..._._-------•--•--•---- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-__-__-.__.-________.___ fq Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water------------------------ P4 -•-•-••----•-----•-------------•............---••.....--•----•••••--•-••--------•---------.................................................................. 0 Description of Soil................................................................................................................................................ -------•--............ U ............................................ ............. ------------- -------------------------------------------------------------------------- ----------•----- ----------------------------------------------------------------------JAA46EI�-------•------------------------------------------------•----------------...----------------------- U Nature of Repairs or Alterations—Ans when applicable.........................._.._.._...____.__....................__.___-_-._._.................... ---- ----------- ---------------•••..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place.the system in operation until a Certificate of Compliance has been iss kd by the board of health. Signed. X......� ..... ., ------•----• ............. 2 / Date Application Approved BY---------- ( . . --....---• /1� l�•'_�.�� Date Application Disapproved for the ollowing reaso s- ----------------- ............................................................................................. .........•-•-•--•-•--...._...•--.....-•-------------•--••------•-•----•---•-••--•--••••....•-•-•--------•------•---------•---------•-----••-----••-------•-----•-•----•-----•---•-----...---••••-•_..... Date PermitNo.--"15--n...7...=................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a.C, ........................ Applir tivu far Ubtipmal Iforks TittivI arthm Pr rrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: /. �y � •6 f .......f. J.,,^ f .,_. �^ .. "".......................... .. ....... v, s `:✓' / Location•Address !' �" �. or Lot No. ° 'r r ............. L. ..,. .f.. ....................................................................W r Owner Address ........... .:........j: .,E... q.y:. ... ...,................................ ................................................................................................... ... Installer Address Type of Building Size Lot........ '{� ;._ .{, ..Sq. feet �., Dwelling—No. of Bedrooms.......` ` .. ............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................. No. of persons.....................------- Showers ( ). — Cafeteria ( ) P4 Other fixtures ------------------• ..:..-•-•---•-••--•-•-•••-•-- W Design Flow........ 0...._...•...................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capae t :A� .gallons Length................ Width................ Diameter................ Depth-............... �1.1 Disposal Trench—No............... __.. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.; I :___;, I?iari`er.................... Depth below inlet.................... Total leaching area_............_._._sq. ft. z Other Distribution boxA ) Dosing tank ( ) aPercolation Test Results Performed by......................•---...-•-----------------------•--••---•••-•----••• Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_-__-________.._.--_. f-T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____________-___.--_--_. .............. -----------...................... ..,...--- •-----------------. *....... ------------------------------ .,.,------------ •---------- 0 Description of Soil......................................................................................••---------•......----------•-••-•••---......................................... >, .. I -•-••• .......... •---------------------------------- -------- W --------------- ---------•--------......--------------------------------------------••-• U Nature of Repairs or Alterations—Answer` when applicable.-___........................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 'X. t i' L w ---------- ------- r .--..... r llate Application Approved BY ............... . -•-••--•-------- ' Date Application Disapproved for the-allowing reaso 'e- ---•--------•-•---••••-•-••-•-••••••.......•••--••••.......-•-----•--•-••-•••-••-••......• ----•----•--..---•• ..---•---------•----------------------------------------••-•-•--•-------•-••••-•--•--•....-•-••---•-••--..-----------•-•--•-••---•-•---••-•-•--•••-----------•-•--••-•-•--•--•---•......••-••---•-•...... Date Permit No.... -­v >...,. ....... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tertifirate of IWITMptiaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( ) !: ., �r`" _ n yd .F -w / -r" ..-„. .- .';.i- -Y'-. j--- '� ......... ._ sue' ✓C:%'- v___at.- --�u;---••-----.4.------ice•-- •-------� _...._._--=- �-- - --r -- --:;�-. ..��. s �. ----------------•- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...V f_'':,-;. ------------------------ dated..__;,,,____��_^'.,1_�-- -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL I' NCTION T ACTOCPY. DATE_ .:... .... ..... ............. inspector .THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............,/' ......OF.....: ?` ., No........:.<f............ —. FEE„ .................... Permission is hereby granted........' to Construct (A or Repair ( ) an Individual Sewa e Disposal System at No r ...... ................ ........... ......:.. ..z:. ' ....� 1 a r�. �:....... .......t.1 ... _._ .. .._. Street as shown on the application for Disposal Works Construction Permit No: Dated__-__: ......... •--- -----------------� --...---- ...................dc ............. Board of 0 ............. Health DATE-----• --4-- -..._. __�............. FORM 1255 HOBBS & WARREN, INC., PCIELISHERS