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HomeMy WebLinkAbout0054 JASON'S LANE - Health 54 Jason's Lane Osterville P _ A = 121 114 MM c ° b /a9 TOWN OF BARNSTABLE LOCATION �� �7" SEWAGE # 2 VU LAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) � / /�7'' (size) NO.OF BEDROOMS BUILDER OR OWNER 1 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) t Feet Edge of Wetland and Leaching Facility(If wetlands exist within 300 feet c ' li ) / Feet Furnished b3 ;l —^ J OP wA6t iNSYhi-'!TUNS LOCATIGN� J `S r"---X DATE �v VILLAGE _(Qskx� ''-ASSESSOR'S MAP & LOT)2 ? �k""Ubgs- INSPECTOR 37 SEPTIC TANK CAPACITY \O©© LEACHING FACILITY: (type) (size) 10®O NO. OF BEDROOMS BUILDER OR OWNER YYl 1E'. J�9.'1C'QXl ei_I OWNER MAILING ADDRESS �j �o �� q� �, �gi r _eye ;.....LL,,+,. .� DEC 2 12004 �7 -• a TOWN OF BARNSTABLE HEALTH DEPT. DATE 11 Ir f/0 4 PROPERTY ADDRESS 54 aazonz Laen Uzte2viiee Ma 02655 On the above date, the740ptic system at the address above was inspected. This system consists of the following:. 1,- 1-1000 gai.eon tank. 2,. 1- Dibt/L"igut"ion Box. 3. 1-1000 ga e eon eeach.iag 12.it., Based on Inspection, I certify the following conditions: 4. 7h.i6 .i.6 a 7.it ee Five SeRtic zyhiem (78Code) 5. The zept"ic zgztem -i,6 in plaopea wo2k.ing o zde2 at the �aeaent t.iMe. SIGNATURE ? Name: Robert A. Paolini Company: Jose-,ph P. Macomber & Son Inc. -:, � Address: P. O. Box 66 Centerville. Mass 02632 Phone: 508-775.3338 or 508-775-6412 9 �� t Z-- J!OSEPH P. MACOMBER & SON;: INC.. Tanks-Cesspools-L,eachfields Pumped .&installed Town Sewer.Connections P.O. Box 66 Centerville, MA.02632-0066 77543$0 . 775.6412• - Page 2 of 11 OFFICIAL INSWTIONTORM—NOT7 FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 54 la,3 on,3 Laen 0,3.te2v.i eie Na Owner:(P.rh�iv 0 smog Date of Inspection: 7 71 Z='/U 4 Inspection Summary: Ghick A;B C;D or.lE/ALWAYVcomp1ete<911 of Section;D A. System Passes: ` NO I have not found any information which indicates that-any of the failure criteria described in 310 CMR 15.303.or in 310 CMR 15.364 exist..Any failure criteria not evaluated are indicated below. Comments: - .Sep.t_"ic AU,6tem .ins .in Pao ea woak.ing 'oizclea at .the paezent time. B. System Conditionally Passes: NO One or more system componentsas described in.the"Conditional Pass"section.need tq 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. NO. • The septic tank is metal.and.over 20 years old*or the septic-tank(whether metal.or:not)is;structurally unsound,exhibits substantialkinf ltratian or exfiltration.or MA.failure.is:imminent. System.will pass inspection if the existing tank is replaced with'a complying septic OA.as-Approved by theSoard of Health. *A metal septic tank will pasi 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: NO 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 it removed distiibtttioii box.b leveled or replaced ND explain: N o The system required pumping more than 4 times a year due to broken or obstructed pipe(s),The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF EI VIRONM!NTAL AFFAIRS DEPARTMENT OF +9NVIRIDI MENTAL?ROTUTION y A TITLE 5 OFFICIAL INSPECTION FORM—.N QT I'ORVOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION Property Address: O�t e2v c �e Ra Owner's Name: Michaee Sweenu - Owner's Address: same Date of Inspection: 11/L 0 4 Name of Inspector: (please print) .i.0 Vie? Company Name:,,g1 1 Pacomap-a & .S.-On Zric. Mailing.Address: Pay - Cer� ezv.c e, � a.sb.•0263�2 Telephone Number: 5 0 8- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system.at this address and that thrm.e of aced o reported below is true.,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in-the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to=Section.15c340.of-Title 5(31-0 CMR,ItS:000). The system: XXX Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority ,Is Inspector's SignOttre: Date: a/o 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•offiee of the DEP.The orig'mal should be sent to•the system owner and copies sentto the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspectidn 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. l T:.,e c TnenPM+Inn T?nrm 6/15/2000 page I Page 3 of 11 OFFICIAL IN PECTION FORM-N©T"R VOLUNTARY ASSESSMENTS SUBStJRF CE SEV�i�-A DjSROS&tL SYSTEM INSMCTI�ON.,FORM PART--A . . CIRTIFICAIRON`(6ontinued) : Property Ad dress: 5� o-asonz Lane �4te2UGQ�e Ta Owner:..N-i hp-ai Sween Date of Inspection: C. Further Evaluation-is.Required by the Board of Health; Conditions.exist whichrequire f u-ther•.eualuation•bthe Board:of Heaithdn•order:to:determine ifthe system. is failing to protect public•health,.safety or the environment. - -a that the 1. System will pass unless Boned•ofl ealth determinestin accordance with 310.CMR 15:303(1)(b) system is not functioning ii�.a•manner�whieb*Ill.protect public health,safety-and the:Mvir-ohmeut: Cesspool or privy is within 50 feet of asurface 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 h functioning in a mariner.that protects thtpHblic health,safety and environment: il absolption'system•(SA•S)-znd the SAS is within 100 feet-ofa The system has a septic tank and so 1_rface.water supply or-tributary to aSurface water supply. _ The system•has•a.sepbe tank and SAS and the;SAS is within a Zone 1 of.a••public wateresupply. _ andthe SAS is within-.50 feet of a private water.supply well. The system has a septic tank and.SAS: _ The system has aseptic tank and SAS and the-SAS is less than 100 feet.biit 50 feet or:zriore fioth 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; Page 4 of I l OFFICIAL--INSP.ECTILON FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSF.ECTION.FORM PART A CERTIFICATIGN(continued) Property Address: 54 I a z o rz z Lan e Owner:Micheai Sweehe.11 Date of Inspection: 7 r10 /0 4 D. System Failure Criteria applicable to all systems:. You must indicate"yes"-or"no"to.each.ofthe:followigg,for_all-inspections, Yes No X Backup.ofsewage:iatcri'4tUty�rsysteini component.due-To.overloaded:or clogged-SAS,or.cesspool X Discharge:orponding of effluent to the.surface 0the:,ground or...surface:waters due to.awoverloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above.outlet invert due to an overlbaded or clogged SAS or cesspool _ X hiquid depth in-cesspool is less thank"below invert or available volume is less than May flow X Required pumping more,than-4 times in the last year NOT due to ologged or obstructed pipe(s).Number of times pumped X Any portion of.the SAS;cesspool or privy is below High ground water elevation. _ X Atiy_portion of cesspool or priy�is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion:ofa cesspool-or.privy is within•aZi one!1.•of a:public.well.. X Any portion of a cesspool or privy is within.50-feet of a private water supply well. X Any portion of a•cesspool or-privy is less than 100 feet but-greater..than 510,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.facllity 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-niust be attaehed.to this€oriq.] . 'N0 -(Yes/No)The system€alls.Ihave determined that one or.momof:the:above.failum.,criteria exist as described in 310 CMR 15.303,therefore the.systeny-fails.The system owner.should contact the Board of Health-to determine what will be-necessary to correct the failure. E. Large Systems: .To be considered a large system the:systtm must.serve.a<:faeility,with-a.design flow of 10,00.0 gpd-to 15iQ00. gpd• .. You must indicate either"yes"or"no"to,each of the following: (The following criteria apply to large systems in addition to the criteria-above) yes no X the-system is within 400 feet of a surface drinking-water supply X the system.is within 200 feet of a tributary,to a surface drinking water supply M. ` X. the:system is located In a nitrogen sensitive area(1nterim Wellhead Protection Area IWPA)or a mapped Zone II of a public water supply well If you have-answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner-or operator of any large system considered a significant threat under Section E or.failed under Section D'shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department, 4 Page 5 of 11 OFFICI'AL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �itBSURFACE'SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART CIiECKLIST Property Address:5 4 Ia z-o zu f n n o , e2v.c e N a Owner: Nichea Sweeney Date of Inspection. 772/0 4 , Check if the following have been done You must indicate"yes"or"no"as to each,of the following:. Yes No s — x Pumping information-was provided-by the Owner,occupant,or Board-of Health X Were any of the system components pumped out in the previous two weeks 7 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 th� 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? Was the site inspected for signs of break out? X Were all system components,i&uding 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 7 X _ Was.the facility owner hand 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 detetm!itaed based on: Yes no X Existing information`..For example,a plan at the Board of.Health. _ X Determined in the'field(if any of the failure criteria related to Part C is at issue approximation of distanc is unacceptable) [310 CMR 15.302(3)(b)] , 5 Page 6 of 1 I OFFICIAL IN- SPECTI:ON::)ORIM`-NOT FOR VOL.UNTARY ASSESSMENT'S SUBSURFACE SE-WAGE DISP.;OSAL SYSTUM:INSPEMON FORM PART.0 SYSTEM INFOR-iATION Property Address:54 7azonz Lane � e2U.c e a Owner:Nicheai Sweeney Date of Inspection: ° FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):.2 ;Number of bedrooms(actual): 33.O�iU D1rSIGN flow•based on-3 Y4D C M• 15.203'�(for exaniple:-I IO gpd z#-ofbedrooins) Number of current residents:, Doesresidence have a garbage grinder(yes or no):n o Is laundry on a separate sewage.sXsiem•(y$f or.no):n o [if yes separate inspection required] Laundry system inspected(yes or no): n o Seasonal use?(yes or no): no 2002-/04, .000 gaeeonz G.-P.,D.-=284.- 93 Water meter readings, if available(last 2 years usage(gpd)):2 0 0 3=10 3. 0 0 0 as J e o n,6 C.-I?.,D.- =2 8 2. 19 Sump pum (yes or no): n o Last date of occupancy: p a e z e n t COMMERCIAL bUSTRIAL Type of esta- nt: N R . Design flgw. '"'rid on 310 CMR 15.203): NR avd Basis.of daign'flow(seats/persons/sgft,etc.): NA Grease trappresent(yes or no):, N A Industrial waste holding tank present.(yes or no):NR Non-sanitary waste discharged to the Title 5 system•(yes or no):NXi Water•.meter readings,if available: NR Last-date of occupancy/use: . NA OMR(describe):. NA GENERAL INFORMATION Pumping Records Source of information; _macnt tank 3/10/04 , P t7acom'ke'z son Inc., Was system pumped as part of the inspection(yes or no): n n If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for.p..umping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a.copy.of the DEP.approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 21 yea2z house 9uiU- -in 1.983 Were sewage odors detected when arriving at.the site(yes or no):n o 6 _ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 54 l a z o n z Lang O�s.te2v.i.Poo l70 Owner:Nich Date of Inspection: 1 / 2/0 4 BUILDING SEWER(locate on site plan) Depth below grade: y g Materials of construction:_cast iron X40 PVC_other(explain): Distance from private water supply well®r suction line: Comments(on condition of joints;venting,evidence of leakage,etc.): A " JO'into a/2/2ea2 .t.i h.t. No 3.i n,3 0 eeaka e., Vented 2oug ouse ven SEPTIC TANK:y e s(locate on site plan) 7000 g a i i o n tank Depth below grade: 1 4" 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: 8' 6"LX4 ' 7 0"&X5' 8"H Sludge depth: Tz a c e Distance from top of sludge to bottom of outlet tee or baffle: .t a a c e Scum thickness: t 2 a c e Distance from top of scum to top of outlet tee or baffle: t 2 a c e Distance from bottom of scum to bottom of outlet tee or baffle:.t How were dimensions determined; m p rz A I d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): In�etOutQet` .tees awe in �ace. 7ank i� �st2uctua�� �souna.- o,s.i n's o Peaka e. GREASE TRAP:NX (locate on site plan) Depth below grade:NA Material of construction:_concrete metal—fiberglass_polyethylene_other (explain): NA Dimensions: NA Scum thickness: Distance from top of scum to top of outlet tee or baffle: NA Distance from bottom of scum to bottom`of outlet tee or-baffle: NR Date of last pumping: N,4 ,-- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural as related to outlet invert,evidence of leakage,etc.): integrity,liquid levels nnf nn� cnnf Titlo S TnorAnt;r,n 17nrm o;/i;/,)Ml1 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:5 e2vc e Owner:.N1.r--k t Date of Inspectlon� ' /L N TIGHT or HQ.I,DING TANK:NO (tank must be pumped at time of Inspeotion)(locate on site plan) Depth below grade: Material of construction: concrete metil fiberglass._,_polyethylene other(explain)- Dimensions NR• - '. Capacity: 4114 gallons Design Flow: NA gallons/day Alarm present(yes or no): IV R Alarm level: NA Alarm In working.order(yes or no): Date of last pumping: NA Comments(condition of alarm and float-switches,etc.): 7 r�oz hoiding tankh a/ze not p/ze,3en1-r DISTRIBUTION BOX: ueA (if present must be opebod)(locate on site plan) Depth of liquid level above outlet invert:no 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.)-. %Abz iY/.j11on Onx hn t 9 in 2/7rj P • Nn 61 ynA •n.4 AQ'Pid nannu nuv-n.t AleLJ nno in an nui OZ anY PUMP CHAMBER: no (locate on sife.plen) Pumps in working order(yes or.no): NA. Alarms in working order(yes or no): N,4 ' Comments(note condition of pump.charnW,condition of pumps and appurtenances,eta.): l�ilmn rhnmOnn ; A nit 7"0 Qgnf Page 9 of 11 . OFFICIAL INSPECTION FORM-NOT-FOR-OLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE.DISPOSAL:SYSTIE-M. INSPECTION FORM PARTC SYSTEM INFORMATION(continued) Property Address:�z e 2 v.oc n z e L a(Ila Owner. N-ichea e Sweeney Date of Inspection: 1 9 i��f r1 l SOIL ABSORPTION SYSTEM(SAS):_-(locate on site plan,excavation-not,required) If SAS not.located explain why: Loca d svv na' lo , Type X leaching pits,number: I leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: _overflow cesspool,number: innovativefalternative'system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level ofponding, damp soil,condition of vegetation, etc.): �-� 6QQrN o i n eye ation i'3 no2mat.' CESSPOOLS:Lo (cesspool must be pumped as part of utspection)(locate on site plan) Number and.configuration:' NR Depth-top of liquid to inlet invert: N,4 Depth of solids layer: N,4 Depth of scum layer: NA Dimensions of cesspool: N4 Materials of construction: N4 Indication of groundwater.inflow(yes or no): NR Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Cezz/?oo e.6 ate no n.t PRIVY: NO (locate on site plan) Materials of construction: N,4 Dimensions: NA Depth of solids: NR• Comments(note condition of soil,signs of hydraulic failure,level ofponding, condition of vegetation,etc.): l2.ivy iz not /22e,3ent , _ Page 10 of 1-1 oMC A1.INSPECTION'-F'O��OSAL 5��".�ORVOLUNTBEG''f30N FORMTS S�$SI�R�A 'SEACE�lI PAR''C • SYSTEM VMR1 ATIOP11(ponti�nved)' Property Address: 54 a.sonz /ano Owner. ��clzea weeney Date of Z �p0 4- SKETCH OF SEWAGE•DISPOSA,L SYSTEM qo Provide a sketch of the sewage disposal system including ties to at lea etwu P laterstthe bu ldingks or benchmarks.Locate g11 wells within 100 feet.Locate when public w pP. ,•�7 low 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY FORM ASSESSMENTS SjJgSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART C SYSTEM INFORMATION(continued) Property Address: U"s te2vii ee !.a OwnerfYl C le a Date of Inspection " SITE EXAM Slope 1 Surface water Check cellar. Shallow wells ` Estimated depth to ground water feet , Please indicate.(check)all methods used to determine the high ground water elevation:-If checked,date ' si •I o obtained from system design plans on recordhole within 150 feet f ofeSA�Sj lan viewed: .lJ observed site(abutting property/observation Checked with local Board ofHealth-explain: Checke4with local excavators,installers-(attach documentation) Accessed USES database=explain: �1i`tPP NA B��n40tbl�-' �—. You must describe how you established the high ground water elevation: used•,Gahert & Miller model 12 1 used•USGS observation w used• Technical bull — — wa ere eva ions. Leaching Pit .,eet Groundwater: Feet Below Bottom-of Pit High Groundwater Adjustment 1.8,ft per VmptejMethod f Therefore,the.vertical•separation distance betwben the bottom,' Of the leaching pit and.the adjusted groundwater table is � f feet. ' • r1 . 1,•r,rnTti.•'n'rrr�Tr.Trrr rtrr°nmrnr+•n+T.*rnsrl:•n•r++.�n+.Tsrn^+m'^at �� . ,I,oWN OF Barnstable [lUARD OF HEALTH 9t)1) t9 1lFACF SFNACE I)ISMSA{� SYSTEM INSPECTION FORM - PART D^- CERTIFICATION r 1 + � mr.+n•n.Trl TwRnrs+rr+r+�r+'T"'•n^vrnlylmrn'r*'+R*'0"rr�"rJ01"�"� .T •.•::1-T.I IM1•••-rr+ -TIPC OR PRIN-T CI.EAPLY- P!t OPERT Y I NSPEC7'ED STREET ADDRESS 54 a�son� Lane e ASSESSORS MAP , D41OCK AND PARCEL Nicheai Sweeney OWNER•' s NAME PA R-7' U - CERT t 1?JrV T ION NAME OF INSPECTOR COMPANY NAhfE Joseph P. Macomber & $on Inc COMPANY ADDRESS B_____X6 Centerville' Mass 02632 Town or Q1 ty state E I P, Street COMPANY TELEPIiONC ( 508 ) 775-3338 FAX ( 508 ) 790-1.578 CERTIFICATION. STATEMENT I certify that I .. hsve personally inspected dorted ith setruewaaocuratosA system this address and that the information ri✓P omplete as of the time of inspection. The inspection was perupgra, and any ' , an 're -air are cosistnt recolninendatiOtis regardl1teriencedin themainpxoperefunctionpand maintenanceeof o with my' training and exp site sewage disposal systems ) Check one : XXXX System .PASSED The inspection which I have conducted has not found any information which indicates that th.e system fails to adequately protect public IIe-a1tII or the environment aas defined stated in the FAILURE 3CRITERIA 03 , f sectiolr c criteria not ailtire evaluated are this form , y System FAILED* The inspection which I hflve conc7ttted has found that the system fails Protect the jiub.lic Iteal. tll and the environment in accord-ance with Titlt 51 310 CMR 1513Q3 , and as specifically noted on PART C - FAILURE CRITERIA of this nspection fo (n.� ate Si nature D Inspector S �• ;ine copy of this c c.t.f ication must .be provided to the OWNER, the BUYER ' '( where apPlicable ) and the 130nRD QP 1iSA7{'I;11, , * .If the. inspection FAILED , �h�e' owr)or or operator, ahal'1 tapgrado • the eyetem within one year of the date of the inspection', unless allowed or required otherwise as provided in 3.10 CMR .1613..051 partd . V COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 N1ILLIAM F WELD TRUDY COXE Govcmor Secretan 9 ARGEO PAUL CELLUCCI B. STRUFLS Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM issioner PART A Q, !� CERTIFICATION RECEIVF� Property Address: 54 JasonSLane , Osterville , MaAddress of Owner: JUL 15 1997 N Date of Inspection: 6/23/97 (If different) Name of Inspector: Joseph P. Macomber Jr. TOWN OFBARNSTABLE am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.Q 0 HEAETHnGvr A Company Name: Joseph P. Macomber & Son Inc . Mailing Address: BOX 66, Centerville , Ma. 02632-0066 Telephone Number: 508-775-3338 � 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 / y Inspector's Signature: Date: C�-' T5�17 The System Inspector all 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. (revised 04/25/97) Page 1 of 10 DEP on the Worid Wide Web: http://www.magnet.state.ma.us/dep Printed on Recycied Paper i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Jason Lane , Osterville , Ma. 02655 Owner: Carolyn Rowland Date of Inspection: 6/23/97 BJ SYSTEM CONDITIONALLY PASSES (continued) .LO 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 lC) 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 CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 6_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: VV0 Cesspool or privy is within 50 feet of a surface water _LD 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: -JI)Q 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. )VO 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 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. Method used to determine distance n1a -(approximation not valid). 3) NOTHER (revised 04/25/97) Page 2 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Jason Lane , Osterville , Ma. 02655 Owner: Carolyn Rowland Date of Inspection: 6/2 3/97 D) SYSTEM FAILS: You must indicate ei;•.er "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. > ,r _ ✓ ,Liquid depth in E I 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 _. NL) Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. ►V0 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. >f Any portion of a cesspool or privy is within 50 feet of a private water supply well. _j/ 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: VV10 : 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 j YUG� the system is within 200 feet of a tributary to a surface drinking water supply t � 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 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Jason Lane , Osterville , Ma. 02655 Owner: Car n Rowland Date of Inspection: $�/ 3 97 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 during that period. Large volumes of water have not been introduced into the system recently or as part 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, )@Kluding the Soil Absorption System, have been located on the site. 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. 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 04/25/97) Page 4 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 54 Jason Lane , Osterville , Ma. 02655 Owner: Carolyn Rowland Date of Inspection: 6/23/97 FLOW CONDITIONS RESIDENTIAL: Design flow:�Gf.p.d./bedroom for S.A.S. Number of bedrooms: O� Number of current residents:,IID4 Garbage grinder (yes or no), NO Laundry connected to system (yes or no): yCS Seasonal use (yes or no):yt'S Water meter readings, if available (last two (2) year usage (gpd): 79S- 14) (7nD Cr[ !t Inn s, ) )� �� � P L-) Sump Pump (yes or no): W D 1 9 9(,,- 3j, !7 o qu )10y)5 1 D 1, 3G C­P D �w)o, )g9'q - g, 0oo GgllonS %J3.�R3 Last date of occupant),: U b1' COMMERCIAUINDUSTRIAL: Type of establishment: 1V0. Design flow: MCk allons/day Grease trap present: (yes or no)_rTA1 Industrial Waste Holding Tank present: (yes or no)__gc�. Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available. wo— rij Last date of occupancy: OTHER: (Describe) YVQ Last date of occupancy: �� GENERAL INFORMATION PUMPING RECORDS and source of information: None rkUa.1 )a�l� System pumped as part of inspection: (yes or no)_V0 If yes, volume pumped: _ Vc-- gallons Reason for pumping �a2GL TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system I'U0 Single cesspool YL Overflow cesspool IVO Privy AT Shared system (yes or no) (if yes, attach previous inspection records, if any) Y77C I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 1A 2S . Sewage odors detected when arriving at the site: (yes or no) Yjo (revised 04/25/97) Page 5 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Jason Lane, Osterville , Ma. 02655 Owner: ro1, n Rowland Date of Inspection: D23/ 7 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron )✓ 40 PVC other (explain) 'io t�vc 12 horse Tank LIF4hT- VrIQhT Distance from private ater supply well or suction line ^11�C�— Diameter 411 _ Comments: (condition of joints, venting, evidence of leaka e, etc.) 11r7,n -��a�� Ylx� s)cns r7F 1�aac�e ScaSrP� �S 12> �d ?f�ia�ah Ali/S� v�ti�T SEPTIC TANK: WOO 9aSby) (locate on site plan) I/ Depth below grade: Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age .�X Is age confirmed by_ICertificate of Compliance �4Yes/No) Dimensions: �� t)IDMI y I(7't IA) IdC Sludge depth: 1 RCXC Distance from top of sludge to bottom of outlet tee or baffle:7V C' Scum thickness: -Tk1kQ'1 Distance from top of scum to top of outlet tee or baffle: —{ cc Distance from bottom of scum to bottom of outlet tee or baffle: M>[ How dimensions were determined: `M PCt cU R c.�- 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.) CC Pt 'r nc4 . GREASE TRAP:- We—(locate—on site plan) Depth below grade: WO- material of construction: ALtoncrete"—)Uetal YIL�Fiberglass WolyethyleneylL other(explain) Dimensions: Y X Scum Alk from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: "I 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.) rr�T-A',-V— `' 20 Y316 T- (revised 04/25/97) Page 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Jason. Lane, Osterville , Ma. 02655 Owner: Carolyn Rowland Date of Inspection: 6/23/97 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: 'I�iGI Material of construction: •Y ConcreteKj&metaIY J Eibergl ass l�LPoI yet hyleneWCbther(explain) Dimensions: YM Capacity: YVCJ. gallons Design flow: C� gallons/day Alarm level: C•L Alarm in working order _,Yes; \;C`No Date of previous pumping: 'A"G= Comments: (condition of inlet tee, condition of plarm and float switches, etc.) Jc (nU ink yml- �T- DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:-Pdc _. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, c.) e v1 c-n cc 0 PUMP CHAMBER: Yvo (locate on site plan) Pumps in working order: (Yes or No) Y Alarms in working order (Yes or No) h1 Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Y�Ih m rx CZfI (revised 04/25/97) Page 7 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Jason Lane , Osterville , Ma. 02655 Owner: Carolyn Rowland Date of Inspection: 6/23/97 SOIL ABSORPTION SYSTEM (SAS):_z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. ) leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: D leaching fields, number, dimensions: (� overflow cesspool, number Alternative system: Name of Technology: n)(- Comments: (note condition of soil, sign of hydraulic fai ure, level of onding, condition f vegetation, etc.) o� .� n�cf tic CESSPOOLS: �Ql� (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: �Kl Depth of solids layer: `(1 CA'^) Depth of scum layer: VI)CA Dimensions of cesspool: 1(1)C� Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) YU� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) oC-) C! P,C. Y)o T- cn 1Z&"-EV1 PRIVY: (locate on site plan) Materials of construction: 0) CG"- Dimensions: W � Depth of solids: YVC-I.- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) noT (revised 04/25/97) Page 8 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 54 Jason Lane , Osterville , Ma. 02655 Owner: Dace r: Inspection: Carolyn Rowland 6/23/97 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) aid 7 cos V1' �s LA� y a (zrvio•d 04/25/97) Pag• 9 of 10 VJ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION (continued) Property Address: 54 Jason Lane , Osterville , Ma. 02655 Owner: Carolyn Rowland Date of Inspection: 6/23/97 Depth to Groundwater I& Feet Please indicate all the methods used to determine High Groundwater Elevation: vv Obtained from Design Plans on record '(�Ubservation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions YYU Check with local Board of health WC) Check FEMA Maps Check pumping records y f5- Check local excavators, installers 1)O Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) J. P.Macomber & Son Inc. Installed septic system at 34 Jasons Lane Permit # 91 -554 No water encountered at 121 (zavimad 04/25/97) Page 10 of 10 `` nn*srr.-nr�-rrear.-:rr.nr.-ris�sr.re-r.rs-.r:•.�+•'r:+v+r:�rr�*mn ns�"ttst+a�rrer.r+ti .. -rn-r-rr-r—r-..- .-. . 1- TOWN OF UOARD OF HEALTH SUBSURFACF SEWA(;F DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION `� �•••t"!�T••.••.:1—�.1 .^�.T Tt�el'R:Tri T'tT�.T.T1f Tt1:T,:rl.'t"11Tr7T1'R1v/—Tf�iTRSq►'IJTTTMSTTRTI m/IfTmiTT,i4-rmrrm.•.—rrrT-�• —. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS _ 54 Jason Lane , Osterville , Ma. 02655 ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Carolyn Rowland PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber& Son, Inc . COMPANY ADDRESS Box 66, Centerville , Ma. 02655 Street Town or City Stet• LIP COMPANY TELEPHONE 508 ) 775-3338 FAX (508 ) 790 _ 1 578 ,t r0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have conducted has found that the system fails to Protect the 'public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 40,�A One copy of t)Iis certification must be provided to the OWNER, the BUYER ( where applicable ) and the I30ARD OF tIEALTII, * If the inspection FAILED, the owner or"'operator shall upgrade ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 . partd , doc �G W THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. Junc 8. 1995 Acting Director of the - ion of Water Pollution Control LOCATION °� SEWAGE PERMIT N0. 157 LAGE INSTA LLER'S NK49E, i ADDRESS ST GUILDER OR OWNER )AI APF s DATE •KERMIT ' I S S U E D ,� DA NE COMPLIANCE ISSUED r 3.' �, �` ///3o%2-, - tqi t AS 4 a q y „a; s _ F No.�CI. � zcs......J�...�.�... e THE COMMONWEALTH OF MASSACHUSETTS �. BOAR® OF HEALTH ................OF..... l �.lj <� Applira#ion for Bispwi al 10orkii Cnnnitrurtinn ramit Application is bat y made-f r-a—Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .....�r . ®9-- ........ ... .h...........One-, s. v� ------------ ------- Lot d ---.......::::::':::.--- Location-Ad ss or j�',... x l 1� -----....... Owner Address a � . ............ .......••••••------. ........................................... .............. Installer Address Type of Building Size Lot____/,........4.0_ .... feet Dwelling—No. of Bedrooms.. .___._____________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building 1� —5 h?'.t1CNo. of ersons....____l__________________ Showers Cafeteria (� YP g -- ---- - P (/ ) — ( ) p-' Other fixtures --------------------------------- - W Design Flow----4s1.0-___-•--••--------•••-_----gallons per person per day. Total daily flow-------- ................gallons. WSeptic Tank—Liquid capacityAW.gallons Length................ Width---------------- Diameter__4-....... Depth.............. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter......4--- ...... Depth below inlet.._................. Total leaching area.__..__._.........sq. ft. Z Other Distribution box ( ) Dosing,tan k ( ) _ '—' Percolation Test Results Performed by._ -----------------•- Date___JUPle _16f_1 aTest Pit No. 1_____ ......minutes per inch Depth of Test Pit................... Depth to ground water.___._____________...._. (% Test Pit No. 2--_-_......minutes per inch Depth of Test Pit.......lil......... Depth to ground water........................ 0 Description of Soil.._.._11�1�x. !'�_ _._f0__F�_xi_. .. 1 x W ----------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------•-------- UNature of Repairs or Alterations—Answer when applicable.____________________________________________________________................................... -----------------------------------------•------------------•----------------------•--•-.---••---••......----------•--•----•----•••---•••...•--•-•••---•--------------••-•-----•-----•--•....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTL y g g p y 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has beengild by the boarrp of heal h. Signed_ . . ------7 �f y Dat Application Approved BY , /�° L ------�" le ate Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- -----------•--------------------------------------------------------------------------------•------------I---••-•-----------.....••-•----•--•----•--------------•-•--••---_._.........--------------•---. Date PermitNo-----................................................... Issued_....................................................... Date No�✓.z .�. 1�..� F: FEs.... .:.f............. THE COMMONWEALTH OF MASSACHUSETTS �•.•.� _ BOARD OF HEALTH tQ ............ _OF .?'. .i§..F..4..!/r-��.i...................................... J�Vp irafton for Mipoiitt1 Works Towitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal St mat: ,,.... �� ...- G.n..._:_..�.h-q::_..D�-r' -�G�---------------------------------- --------•- .................................... Location-Address or Lot No. ------•...............».........-..----•-•-^--•--•--...._.....-•-----••-•----••--•-------------- -------------------••-----•----•-•---••-----•.._..••-•--•----=•--..._....-----------------•------. owner Address Installer Address Q Type of Building Size Lot._ ...Sq. feet Dwelling—No. of. Bedrooms_ .___._ ..................Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building .1Q�-,4 e. 'xte No. of persons....... .................... Showers Cafeteria ( ) G4 Other fixtures ---------------------------------- - Design Flow---ZIP1......__._ allons er person per day. Total daily flow_......_ W - g P P P Y• Y �...........==----gallons. WSeptic Tank—Liquid capacitl/'t ._.gallons Length................ Width..__...__._...._ Diameter._. Depth.... x Disposal Trench—No. .................... Width_—_____-_--_-___-- Total Length.................... Total leaching area....................sq ft: meter..... Depth below inlet.....__......._..... Total leaching area.........._.......sq. ft. Seepage Pit No----------_-------- D?ca Z Other Distribution box ( ) Dosin �nk ) Percolation Test Results Performed by._- �.Q--- _e y_�_".S.Gtt.I:-Z Date__,�_�_17_ ._/'.---- ,aa Test Pit No. 1....A.......minutes per inch Depth of Test Pit___'A........... Depth to ground water........................ Test Pit No. 2-_--.......minutes per inch Depth of Test Pit.._...IV.......... Depth to ground water........................ µ Ra ----•-----------------------------•-----------•-------•---------. ----------•---•--•----------.......................................................... O Description of Soil---y V.PA.... --------------------------- x x --- ---------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------....................................... ----------------------------•------••---------------------•-------------------------------------•------••--••----------------------------------------•---------•---------•--•-•------.............---- Agreement: _ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T T � y g g p y 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in p p y the/boayof hea.h. o eration until a Certificate of Com liance has been dSigned----•-•. % . . "€ �19-1A D to Application Approved By...... ------------••-•-- ••- ij Date Application Disapproved for the following reasons-----------------------••--------------------------------------•-----------------•--------------------...-•---_.. ......--•----••---•--••-•....---••----------•---------------•---•---•---•--------•------•.......-•--•-••---------••••--•----•----------••--•-----••-------•----•---------------••-----•----••-•--------• Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................................_OF..................................................................................... �� �rr�ifirtt��e laf �f�unt��i�nre �- . _ . rTaH1S. IS-!'TO.ChRTAfiY, That the Inavidtial-Sewlike D}sposal-System confstructed '( or.'Repaired ( ) by - --:-%_ ..... -------------------•--••---•--•----•-------•-•----•....... ..-•---•-•-•- •-•-•--••- at.....................�L.�.�/,----•1''P ------- lti_11� 5.l_f"''___._-................................................................. has been installed in accordance • 1 the provisions of TIT Li j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._,8.x_-,?o0. ..:............. dated_............................................. THE ISSUANCE OF THIS CERTIFICATE SHAd PLOT BE CONSTRUED AS A GUARANTEE THAT THE n SYSTEM WILL FUNCTION SATISFA CTORY. ,a DATE...........................................8 a•l-• &..----•--••-.._.._.. Inspector...............` A --------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6 ....................OF..................................................................................... a&!.Nz:'_?^. FEE... 1............... Dis sal Works T-5nngtr rr i# Permission is hereby granted.......... �' to Construct or Repair ( ) an I ' •dual S . 'age iv osal Syst at No............ �'� r� -------- ----------- Street as shown on the application for Dispos N1rorks Construction Permit No....................: Dat ............__....__...._........_....._.. d of Health DATE........................................e -------------- FORM . _... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS/// THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) mF DATA pts�•.Bgc L //�� / // __ 1 Qoo Goal, . Z� aea Go�Jc•l.�ac�+� � r�;;. aoea. Sip}'� �'�"�� 5�•� �a a°a a Q A Pr, AA �►. '' I S•6 AAA , ��1 2�wa-Ards 54ry os-D ttg000 D © � LfloT• PST EaLV r � I/ aid S D es 1G N rA 2cot..aTtunt .L T�.'. : �.� N roc T 'ST '.Ft 'oRM� ,,E, ;_1 ! 982 PD LAAcwuc-, �( . �-�'�erpt�ar.� : � ��,►P1a,G i ry �iZa�t.�t� �D : , �" 5�4t�A 73a7-r6t.4 7T-5 x Lt 04 St ads f o k 71-2G PD GPP 47 b tsPdc� � t t? 3It,lt'�t� r .._. �►E�.oRCAN�.� Val � Tf� . �O�t'S1 a NS �.� r •� r 4l- t168 . Lra- - oq W00D5