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HomeMy WebLinkAbout1006 MAIN STREET (OST.) - Health 1006 MAIN STREET, O�STERVILLE A= 118106 1, o G 1 G 13Abk C DTrA9'; TOWN OF BARNSTABLE LOCATION I 0 Q(01NJ�1�1 ST SEWAGE # PILLAGE Os're(Ut14 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY CIIN LEACHING FACILITY: (type) ��T �X�a� (size) NO. OF BEDROOMS BUILDER OR OWNER SC UT�i, PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi facility) Feet Furnished by on �D/� t GoTA�c iaaa� ao a a� ao 3 yo a8' 3 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1006 Main Street(Cottage) OsteMlle. MA 02655 Owner's Name: George&Eunice Scotti Owner's Address: 30 Middle Road East Greenwich, N 02818 . 1 c Date of Inspection: June 21. 2005 t Name of Inspector: (Please Print) James M. Ford r` CZ Company Name: James M.Ford < Mailing Address: P.O.Box 49 L Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT r— M, rri I certify that I have personally inspected the sewage disposal system at this address and that the inQjrmation reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: June 27. 2005 The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of complete g this inspection. If the system is a shared system or has a design flow of I0,000 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1006 Main Street(Cottaze) Osterville. AM Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. 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: 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1006 Main Street(Cottaize) Osterville. MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1006 Main Street(Cottage) Osterville. MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/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 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-.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 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1006 Main Street(Cottage) Osterville. MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1006 Main Street(Cottage) Osterville. MA Owner: Georlre&Eunice Scotti Date of Inspection: June 21, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 1+ Number of bedrooms(actual): I DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 Number of current residents: Unknown Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Unknown Water meter readings,if available(last 2 years usage(gpd)): _ Both houses:2004- 14.000 gals.:2003-19,000 als. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/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: Installed on 7123176-per as built card Were sewage odors detected when arriving at the site(yes or no): No 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: 100 5 Main Street(Cottage) Osterville MA Owner: _George&Eunice Scotti Date of Inspection: June 21 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 8" Material of construction: ✓ 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: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping'recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were resent. The li uid level was even with the outlet invert. There did not a ear to be an si ns o leaka e. GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1006 Main Street(Cottage) Osterville. km Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarr►level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1006 Main Street(Cottage) Osterville, MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 6'x 6'(1000 aaL) 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 leach nit was dry. The scum line was annroximately 1'up from the bottom There did not appear to be any signs offailure The bottom to grade was 7'. CESSPOOLS: None (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): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 _ J r Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1006 Main Street(Cottage) _ Osterville. MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM 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. C,oTASc 3 taaa� � o a 3 yo ag 3 10 • Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1006 Main Street(Cottage) Osterville. MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours snaps, the maps were showingapproximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1006 Main Street(Main House) Osterville, MA 02655 Owner's Name: George&Eunice Scotti Owner's Address: 30 Middle Road East Greenwich, R102818 Date of Inspection: . June 21, 2005 1 Name of Inspector: (Please Print) James M. Ford .. Company Name: James M.Ford r" t 'Mailing Address: P.O.Box 49 ix Osterville.MA 02655-0049 Telephone Number: (508)862-9400 --- CERTIFICATION STATEMENT _ c✓� I certify that I have personally inspected the sewage disposal system at this address and that the in rmatiori zeporta below is true,accurate and complete as of the time of the inspection. The inspection was perform d based on my rya training and experience in the proper function and maintenance of on site sewage disposal systems I am a DEP`� approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: June 27, 2005 The system inspector shall sub 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 1.0,000 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 ****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 h conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1006 Main Street(Main House) Osterville, MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. 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: B. System Conditionally Passes: One or mores stem components as described in the"Conditional " y p oval Pass section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1006 Main Street(Main House) Osterville, MA Owner: Geor-ae&Eunice Scold Date of Inspection: June 21, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1006 Main Street(Main House) Osterville. MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓. 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be.considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: , (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1006 Main Street(Main House) Osterville, MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1006 Main Street(Main House) Osterville, MA Owner: George&Eunice Scotti Date of Inspection: June 21. 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: Unknown Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Both houses:2004- 14.000 gals.:2003- 19,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL 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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping:. TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/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: Installed on 5116189-per as built card Were sewage odors detected when arriving at the site(yes or no): No 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: 1006 Main Street(Main House) Osterville, MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 14" Material of construction: ✓ 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: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakaie. GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1006 Main Street(Main House) Osterville,MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 TIGHT or HOLDING TANK: None (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: eallons 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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (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.): 8 t a Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 1006 Main Street(Main House) Osterville. MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1-6'x 6'(1000 ag_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: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The leach nit was dry. There did not appear to be any signs offailure. The bottom to grade was 9' CESSPOOLS: None (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): Comments (note condition of soil;signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1006 Main Street(Main House) Osterville, MA Owner: George&Eunice Scotti Date of Inspection: June 21. 2005 s SKETCH OF SEWAGE DISPOSAL SYSTEM 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. r 8 P, (3 a o 3a 13 -y I 10 Page I of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) ' Property Address: 1006 Main Street(Main House) Osterville, MA Owner: George&Eunice Scotti Date of Inspection: June 21, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Usintr Barnstable topographic and water contours maps, the maps were showing approximately 25'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied, relating to the system, the inspection and/or this report. 11 v Commonwealth of Massachusetts Executive Office of Environmental Affairs RECC -u r Departmont of ,. �_ � Env1ronmental Protection sEP 1 0 Wllllam F.Weld HEALTH Qep� Cw amor 10WU OF BAFNS�"A LE Trudy Coxe ,EOEA . David S.Struhs commbaioner SU35URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION , Property Address: ��Q (o rnQ.� S� Ci�Address of Owner: f�( Date of Inspection: 'Z (._ 96 1 (if different) _ Itle— c27E< Name of Inspector: Z:y ajo ndJa N Company Name, Address Telep� & Number. CERTIV ATIkST TA EM Ii�e"eW ,` 1'&U ! 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 main enance of'on-site sewage :Iisposal syste�stL, t e system: , _Passes _ Conditionally Passes Needs Further Evaluation.By the Local Approving Authority Fails inspector's Signature: 6 Date: _ 7`„1Tg6 the:�3—stem inspector shall submit a.copy.of'this inspection report to the Approving Authority within thirty (30) days of completing this inspei--;ion. If the system is a shared cysterr,.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 oviginal should be sent to the systern owner and copies sent to the buyer; if applicable.and the approving authority. INSPFC'TION SUMMARY: Clieck A, B, C, or D: , A( SYSTEM PASSES: I have not fcund ary information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not e-aluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: 1 /r One or more system components creed to be replaced or repaired. The system, upon completion of the replacement or repair, passes impection. Indicate yes, no, or not determined (Y, N, or ND): Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised B/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)5W1049 a Telephone(617]M-11"- f. ( Panted on Recycled Papa r 4 r V i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C.' PART A CERTIFICATION (continued) Property,Address: Owner: Date of Inspection: }y t B) SYSTEM CONDITION LY PASSES (continued) _ Sewage ckup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or d to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Hea h): \ broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required p\minf more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with appf the Board of Health): broken pipe(s) are replaced obst uction is removed. C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation b�j 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 SA\ETY 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 O"EALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MA NER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank nd soil absorption system am\tsithin 100 feet to a surface water supply or tributary to a surface water supply. _ The system ha, a septic t k and soil absorption system anithin a Zone I of a public water supply well. _ The system has a septic ank and soil absorption system and is within 50 feet of a private water supply well. — The system has a sep tank and soil absorption system and is les than 100 feet but 50 feet or more from a private water supply well, unless./ nless 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 nitro and nitrate nitrogen is equal to or less than 5 `` ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failutxa 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 }'l the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. t (revised 8/15/95) 2 1 1 S a ,J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: l OC) — Owner: Date of Inspection: D] SYSTEM FAILS(continued) Static liquid le I in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in ces \ is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping mor than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorp ion 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 'thin a Zone I of.a public well. Any portion of a cesspool or privy is with' S0 feet of a prrva" to water supply well. Any portion of a cesspool or privy is less tha 1Zfeet ut greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the we.11'h s been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic com ou ds, a• monia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to arge systems in addition to the crite i above: The design flow of s st is 10,000 d or greater (Large System) and the system is a significant threat to public health and safe g Y gP g g Y ) g P safety and the environment ecause one or more of the following condition exist: the s em is within 400,feet of a surface drinking water suppl e system is within 200 feet of a tributary to a surface drinking titer supply the system is located in a nitrogen sensitive area (Interim Wellhead rotection Area (IWPA) or a mapped Zone II of a public water supply well), The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: q SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: _ ncrete _metal _FRP other(explain) Dimensions: L r� Sludge depth: All Distance from top of sludge to bottom of outlet tee o r baffle: 2 Scum thickness — `Q `� l Distance from top of scum to top of outlet tee or baffle: 2- Z Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet t s or baffles, depth of liquid level in relation tooutlet invert, structural integrity, evidence of leakage, etc.) zi — T 77:�g'g U GREASE TRAP:_ (locate on site plan) Depth below grade\ Material of construction: _concrete metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum.to top of outlet tee or baffle: Distance from bottom nf Snom t� bottom of ou -t�tee or baffle: Comments: (recommendation for Mping, condition of inlet and outlet tees or baffles, depth of i id level in relation to outlet invert, structural integrity, eviden o leakage, etc.) 6 (zevised,8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Adds M Owner: a, v Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: gallons lt?�-2— «� Number of bedrooms: Number of current residents:_Z Garbage grinder(yes or no):,4,0 Laundry connected to system (yes or no):� Seasonal use (yes or no):& Water meter readings, if available: /9 9� Last date of occupancy: A// v �� COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present:!(yes or no)_ Industrial Waste Holding ank �nt: (yes or no), Non-sanitary waste discharged to the Title-5 system:stem: (es-or no)_ Water meter readings, if meter readings, if available Last date of occupancy:: OTHER: (Des 'rb'e} _ Last 'at occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: / it<Qu7 System pumgfd Is part of inspection: (yes or no)_.#, — ¢ ,Z If yes, volume pumped allons Reason for pumping: ��� 6�•,cp��.' TYPE OF YSTEM U 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: A4e'.c� , Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ��,� Owner: U"� Date of Inspedioa: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. ne 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 ag part of this inspection. fAs�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 CF116'site was inspected for signs of breakout. L system components, excluding 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. —T'�' he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _T— he facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS TEM TEM INFORMATION (continued) Property Address: a Q Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on*srte plan) Depth below grade:\ Material of construction: concrete_metal _FRP other(explain) Dimensions: Capacity: Rallons Design flow: >;allons/day Alarm level: Comments: (condition of inlet tee, con on of alarm and float switches, etc.) DISTRIBUTION BOX: Z `�, jjcYx Z3 (locate on site plan) Depth of liquid level above outlet invert:'%' Comments: r (note if level And distribution is qua!, evidence of solids carryover, evidence of leakage into or out of box, etc.) (1 c+—z, _d-g _ jL PUMP CHAMBER:_ (locate on site plan) Pumps in working order.(yes or no _ Comments: (note condition of pump chamber, condition of u ps an appurtenances, etc.) (revised 8/15/95) 7 -5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ((.3 6G s � y 14Q Owner: i Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):-t' (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: 1,64> leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (no le condition of soil, s' ns o hydraulic failure, level o ponding, co ion f vegetatibn,et .) /Vd CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspectio Comments: (note condition of soil, signs of hydraulic ure, level of pondi g, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of con t uction: Dimensions: Depth of so' s: Comme : (note condition of soil, signs of hydraulic failure, level of ponding, condition of veg�aii n, etc.) (revised 8/15/95) 8 I I r, `yam • e It's. -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C _ SYSTEM INFORMATION (continued) _ x AA ' cam, �-- Property Address: CC3C�C �S�- s` Owner: Date of Inspection: Q/ ,b SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at leasi two permanent:references landmarks or benchmarks locate all wells within 100° a 2U ® d J. DEPTH TO GROUNDWATER f � Depth to groundwater: feet j method o determinati n or approximation: 4xI G 7 (revised 8/15/95) 9 f _o Commonwealth of Massachusetts. J 1 .y 1 � GEC C� 7 Executive Office of Environmental,Affairs,r �� Department of r._ f.A JUL 1 9 1996 Environmental Proe�� io=n ' e� Wllllam F.Weld Gown« - Trudy Wxe , SaenMary,EOEA • David B.5tiuhs Commhaionar SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: rn Q„t,AL ©Address of Owner: Date of Inspection: -7_ t 96 Of different) Name of Inspector: j��l�l, Company Name, Addrre�ss and TelepTil eN 4er: �T F' M cfz f ti 3(. 2_ 30�.c> CERTIFICATION STATJyS e4 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 i Inspector's Signature: Date: 7— 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 16,000 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: y 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. i Bj SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N,.or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or 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 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(611)SW1049 • Telephone(611)292-5500 Printed on Rwyded Papa ,i b� J.SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . U�� CERTIFICATION (continued) Property Address:Tq:a�T-��� Owner: 4 :i2=14RAO T-t)Vie'CT Date of Inspection:.--ww- B] SYSTEM CONDITION LY PASSES(continued) Sewage up or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or d to a broken`, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Hea ): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pum 'ng.more than four times a year due to broken or obstutcted pipe(s). The system will pass inspection if(with approval of the Board of Health): b?gQken pipe(s) are replaced obst uction is removed ' C] FURTHER EVALUATION 15 REQUIRED BY THE BOA D OF HEALTH: Conditions exist which require further evaluation b the Board of/inn determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH D ER INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND S FETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a su ce w ter Cesspool or privy is within 50 feet of a rdering getated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF EALTH (AND UBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MA ER THAT PROTE THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. _ The system has a septic tank nd soil absorption system an is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system ha- a septic t k and soil absorption"system and is within a Zone I of a public water supply well. The system has a septic ank and soil absorption system and is w'thin 50 feet of a private water supply well. The system has a sep' tank and soil absorption system and is les than 100 feet but 50 feet or more from a private water supply well, unless well water analysis for coliform bacteria and v Iatile organic compounds indicates that the well is free from pollutio from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPm• D] SYSTEM FAILS: I have determined t at the system violates one or more of the.following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below: The Board of Health should be contacted.to determine what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 Owner: Date of Inspection: DI SYSTEM FAILS (continu Static liquid le I in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in ces I is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping mor than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorp'on System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or pri is within 100 feet of a surface watery supply"or tributary to a surface water supply. Any portion of a cesspool or privy is ithin a Zone I of a public vyelf. ' Any portion of a cesspool or privy is wit ' 50 feet of a pri ate water supply well. Any portion of a cesspool or privy is less tha y00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the w s been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic com nds, a monia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: The following criteria apply t arge systems in addition to the cri ria above: The design flow of syst is 10,000 gpd or greater (Large System) a the system is a significant threat to public health and safety and the environmen cause one or more of the following condition exist: the s em is within 400 feet of a surface drinking water suppl -the system is within 200 feet of a tributary to a surface drinking ter supply the system is located in a nitrogen sensitive area (Interim Wellhead rotection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ( (7 Q MIL Call— �j Owner: t1-� Date of Inspedia. Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. G-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. 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. v'The system does not receive non-sanitary or industrial waste flow si a was inspected for signs of breakout. C,Alr ystem components, excluding the Soil Absorption System, have been located on the site. �e 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. he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _The facility ov.'ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Add : (�Q Owner: l <`7 Date of Inspection: �1 RESIDENTIAL: FLOW CONDITIONS • Design flow: gallons Number of bedrooms: _ A Number of current residents:_L Garbage grinder(yes or no):,,Jjj Laundry connected to system (yes or no):� Seasonal use(yes or no):An Water meter readings, if available: 11100 Last date of occupancy: ! COMMERCIAUIN DUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ - Industrial Waste Holding Tahk-pce`nt: (yes or no)_ Non-sanitary waste discharged to the Tit 5 system:..( r-rro)_ Water meter readings, if available: Last date of occupancy:_ OTHER: (Des +be) \ Last dat occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: -- System pum d is part of ins ction: (yes or no)_# _ ¢ .2— r If yes, volume pumped J� alk Reason for pumping: TYPE OF SYSTEM L/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) Other(explain) APPROXIMATE AGE of�all components, date installed (if known) and source of information: `'!y -�-� g l to Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C! SYSTEM INFORMATION (continued) Property Address: Owner: c. Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: 4-co-n-crete _metal _FRP other(explain) ; Dimensions: Sludge depth: 2 y�� # 2— Distance from top of slulcige to bottom of outlet tee r baffle: Scum thickness 1 — `d " 2 45 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Z Comments: (recommendation for pumping, condition of i let and outlet t s or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) AU" � U 6 GREASE TRAP:_ (locate on site plan)— Depth belo,.%, grade: �onc �ei Material of construction: al _FRP—other(explain) - Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom ns<<,�m t- bottom of ou a or baffle: Comments: (recommendation for ing, condition of inlet and outlet tees or baffles, depth of i u�d level in relation to outlet invert, structural integrity, eviden leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (0 p Q� Owner: / L) Date of Inspection TIGHT OR HOLDING TANK:_ (locate on�`site plan) Depth below grad. Material of construction: concrete_metal_FRP_other(explain) Dimensions: Capacity: eallons Design flow: eallons/day Alarm level: Comments: (condition of inlet tee, con 'on of alarm and float switches, etc.) DISTRIBUTION BOX: l ji&e -1> � . (locate on site plan) 'Z _ `�d Depth of liquid level above outlet inve % = 6 2_ Comments: (note if level nd distributio^ is qua!, evidence of solids carry-over, evidence of leakage into or out of box, etc..) cle L d Aig IF PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no ---'"� Comments: (note condition of pump chamber, condition of ps appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (b 4y,, Ma44A S - 14Q Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):¢/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_* 7— ' leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (no le condition of soil, s' ns o hydrau ' failure, level ponding, condition vegetation,et .) Ad ./Z 47 CESSPOOLS: _ (locate on site plan) Number and configuration:_ \ Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: - Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspectio Comments: (note condition of soil, signs of hydraulic i ure, level of pondi condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of con uction: Dimensions: Depth of so' s: Comme : (note condition of soil, signs of hydraulic failure, level of ponding, condition of Qn, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ll.3C' n'I din Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' A i � c DEPTH TO GROUNDWATER Depth to groundwater: l feet method o determinati n or approximation: G cs' Zty+t IIAv /%tom u y'. (revised 8/15/95) 9 t MAI^ H ovst. TOWN OF BARNSTABLE LOCATION f 00(0 ►tiAIA ST— SEWAGE # VILLAGE 0Xr4.rv1 1 Lt ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �� / /D� SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) PiT (0X(0--* (size) /CqM NO.OF BEDROOMS 3 BUILDER OR OWNER SC 011- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any_wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of lea hing facility) Feet Furnished by. �nSac�,inn S Forl A A 6 a o I l a a� 3 3a� 13 y Y ell i g " �; TOWN OF BARNSTABLE LC;•CA'i"IL`N tdd� & 6 iA/ SEWAGE # IILLA.GE re 1//LL e ASSESSOR'S MAP & LOT 0 1 INSTALLER'S NAME & PHONE NO. J'p -)A SO SEPTIC TANK .CAPACITY Ooa LEACHING FACILITYAtype} % OOd (size) { NO. OF BEDROOMS PRIVATE WELL-OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: c DATE COLIPLIANCE IS VARIANCE GRANTED: Yes No !L �i i h � - � � � ,�� \ `1, { '`� ,�` d w �, s FEE.... 2.0 M).. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .............Town..................OF...................-B.ar.ns.ta-b1-e-----------_---•------------------ Apptiratiun for Bi-spaa al Workg Tunu.trnrtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: .... 1006 Main Street O s ter V l,j.a-.a................ •......---••.....------.........--------•--------.........._._....------......--•---..........•... Location-Address or Lot No. F.o11.y...T.a-yl.nr-........................................................... --•-••-•---••----•--......-•-•---•----...--------•--------•-•--------.........................---- Owner Address a .... ................................................... .................................................................................................. Installer Address dType of Building Size Lot............................Sq. feet Dwelling gXNo. of Bedrooms...._......3...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.....................---.--. Showers ( ) — Cafeteria ( ) Other 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 ( ) f aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....-.-..---.---.------- a ..........-.................................................................................................................................................. 0 Description of Soil....................................................................................................................................................................... V ..............................................................S-and...&...Gray..e1...................................................................................................... W ------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------••......••••. U Nature of Repairs or Alterations—Answer when applicable-1:71.0.0 Q.--g.a.11 on...t-ank........................................... ------------------------------------------------------------------------------•-----------------•---.....1-1.0.0.0•--.gaLl.on---laa.ch...pit.....-------------•----••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'i T IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issu d W th board of iealth Signe ,..01 ......................... ....5/4 •&9----•..-•-•- at Application Approved, By.... l ................................................ ......,a'�=:�,� Date Application Disapproved for the following reasons:-----•--------••-----------------•--•-------------------------•----- ......................................... -••----•------•------•------••-------••--•---•---•-----------••-----------------•----------•-••--•------..--.....•-•--.....-----•------------------------------------------------......-•---••••-.------ Date Permit No._1-. : ............................. Issued._. P Davt THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) IM A I / �C(�'J L DATA k No......................... Fms................ ...._... . THE COMMONWEALTH OF MASSACHUSETTS 111 BOARD OF HEALTH OF.. - Apphra tion-for Dispoii al Works Tomitrurtiou lirrmit Application is hereby made for a Permit to Construct ( ) or Repair (X)• an Individual Sewage Disposal System at: ..... �_._.._..� ............. . :........_..........._..._... ----•-•----•------------......•...••..._..........__.._......______.._.....•------•...__.•------- Location-Address or Lot No. _ r Owner Address W °0--------------------------------------------------"' " 'Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling-RXlo. of Bedrooms............................... .Expansion Attic ( ) Garbage Grinder ( ) _________- No. of persons............................ Showers — Cafeteria Other—Type of Building ________________�_ p ( ) ( ) p" Other fixtures ..................... Q -------------------•------------ ------ 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 ( ) Percolation Test Results Performed by........................................................................... Date........................................ Test .Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----___-__-•___•._____- 9 --•-----•---------------------------•--------------•---------•----------•--•••...........-----•--•--.......................................................... 0 Description of Soil........................................................................................................................................................................ x ,, W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable-----1_-_' 9...... 1. _O'�__.t.7'r,"=................................... 3` Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of A.- I p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issul 11ed by the board of.health.. Signed (� Y�t/•.. f� f � .�------------- Application = = r Date Aroved B •----------'��........-•---------••----•--------------•--•......••-•-•-- PP Y ;fir /Date / Date Application Disapproved for th w easons---------------------•---------------------------......------ ...-•-•---.._ ---•-----•-•---------•---------------------•-•-....•-•••--•-••-••••-•--••-----•-----•--••--•-----••-••--- a¢ Date Permit No........�-Q-- ----------------------- Issued__-----_ '/ Qa �r --�.._- ---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trdif irFatr of TompliFaurr THIS IS'TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired bY---••---- - . "° --. _y. ....................................... --••------•-••--•-•---•-.....-•--•-•-••••-••---•----•----•-•------••--............----•-••-------••--- Installer has been installed in accordance with the provisions of T I T IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No_____________ il......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SMALL NO E 40NSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... _ _-l-_✓_ ,...----•--••---•-•••._._.... Inspector------------------- , _-----•-----•------------••----•----•--__--• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .Otxt't..............OF................@3 rn.st. ble No......................... FEE..._. ...�0=(30 J.0.Macomber Jr. -Big vD a1. orku �ouitrar#iou amit �^(� y;..r 7 rctvb AIt Perm>ssionl iS�'ttreti}� raanfe ----------------•__--_._-•..--_ ------------------------------------•---•------------------•--•,.........-•--___..---......_.... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo...............................................................................................................................------......................................................... Street as shown on the application for Disposal Works Construction Permit No............ ��..<d ted.................:........................ •----•------------------------------•••-- -•................................................... ot Health DATE................................................................................ 19" 64 FORM 12581 HO S A INC.. PUBLISHERS -al,-OCQ,TION : SEW&C.,E PERMIT UO. - VILLAGE - - - - - - - IMSTQLLER'S- U&NIE ADDRESS -�S, -1 - �l Aaa - 7�d BUILDER'S ADDRESS MITE PER"VT ISSUED DATE COMPLI &KiCE ISSUED ; l 1 dDC� A-. - „ �u sue' �. . ,- f , � Y,�" `� �\ � yd. �8 l ................. Fa o........._ THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH ..(.. ...........OF..... .....W I.S. -- �......... ....... Apphratiurt -fur Di,spugttl Workg Tonstrurtiutt Pprutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 4 T' ........................ -1 d-�-•�•-=-- 4_z4fr1'C�.;ioV(-.Addressn1..........•-•-------------------•----------- mac..._... ...--------•-- It, or Lot No. , 5= ------------------------------------ -------------•--•••-------------•••-----•-•-•------------------•---•----......................... Owner V ....Add s Insta er 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 ( ) d Other fixtures -------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacitv!P7P70gallons Length................ Width................ Diameter---------....... Depth..-.------------ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area...............-----sq. ft. Seepage Pit No._1_ ... Diameter... Depth below inlet.................... Total leaching area------------------sq. it. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date----- ------------------------------.... Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water.-.----_..--.-.---..---- �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water............--.------.-. O Description of /eZ_1 tl 1-- x --------------------------------------------------------------------------- •----•......--••-•-•••-•--•-•----------------------------------------------------------------------------------------- W x -------_. � ------'----------------------- V Natu f Re airs or Alterations—Answer when a pl' ble.. �"�.t1Ci��ftiC- .......:...........----.--..-..--.-_.----.-----. ----.. _mac 1- �:�e... Q�.. lG' t --------------------------------------------------- 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 be issued b he board of health. ined --------••------ ---- `/ - g J / D Application Approved By...... %� �� 1 � j� Date Application Disapproved for the following reasons:................................................................................................................ ----------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date Alf c` r , y I .... ........................................... .......................................................------...ne.. N .... -•••-••----- F>��� - .Q0........_ THE COMMONWEALTH OF MASSACHUSETTS BOARD.�OF HEALTH ........ OF..... '-r_d,4 -ter......................... Appliratioo -for Bi,ipoial Worko Tonotrortioo Prrmtit Application is hereby made for a Permit to Construct ( ) or•Repair ( ) an Individual Sewage Disposal System at: catio -Address or Lot No. --------------------------------•------• /Z`= --6 1.•----•............................ .•-•--•-•----••--••----�.••-•••--•--� caner Addr `- Insta er Address Type of Building Size Lot----------------------------Sq. feet -, Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --•--------------------••------------------•........................................................................................................ Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacityl gallons Length................ Width-------------_.. Diameter-----........... Depth---------------- x Disposal Trench—No- ____________________ Width-------------------- Total Length------------_----_ Total leaching area--------------------sq. ft. Seepage Pit No._J_ �___ Diameter___- Depth below inlet____________________ Total leaching -area ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------------------------.......................................... Date___-_______--------------_-------------. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---___-______-___-__---- G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 9 el-I ------------------------------------------ ---------------------•--•-----------•------------•----------•---•---------•----------------------------•---------- ODescription of SoihL 3tG --------'--------- ----------------------------------------------- --•---•--•-••----- -----------------•- x ••••--••••'----•-----------•-----------•---------------------------------- ••••••-•••--•---••--•-••----•-•--•---------•••-•---------------•--------------------------•-----•-••-•----•------------ Z r` U Natut~ of Repairs or Alterations—Answer when appl' ble.-. ---------- .C_ .............______________--- �'l� -- --------------�.�1 ---------------------•-------------•------------•-•--•-•-- ------------------------- 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 b he board of health. igned-='-`rram--�- -------------------j-e �� Date Application Approved BY-----...... --------- --- _•• - /--•------------- ----- . � --�-� Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ •-••••••••••••-•••-••-•••--••••••••-•-----------------------•--•••----------••---...--••-•-•-••--•---•----------•--••--------------.._..-••••--•••-•--------------------------------------------------- Date PermitNo-----------_-------------------...................... Issued........=............................................... Date THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH . �" "............oF...<��Cc�2z�.,S..�` -�.......................... Trrtifiratr of Tompliaurr THIS1W TO CErTIFY, That the Individual Sewage Disposal System constructed (//)'or Repaired ( ) by `� -z �y ------------------------------------------------------------ I all 1�1 C '� �-- ( - ------ �^- ��------ has been installed in accordance with the provisions of Art XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-----__________-S_f-__y--------- dated..... .2.7------74......... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS 4 GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACT RY. DATE------ _- ........... -.-. Inspector------------------ ... -- -- - -------------------------- i THE COMMONWEALTH OF MASSACHUSETTS 6 BOARD OF HEALTH _ 2 _ Iry ' .. No......................... FEE' --I-.............. �i��o ttl ork,� .C�oo�tror�ioat �rroti� Permission is hereby granted---- ��-r-------- 4215"S -- ''--------------------------- ---------------------------------------------- to Construct-- or Repair ( ) an I ividual Se e Disposal System ,�" Y fv � --------=-•-- = -- at No.--- ---------- Street as shown on the application for Disposal Works Construction Per . No_______ _____________ ated_._- 'z_�'__7..4____.-.-___. _ oard of Health DATE....� -'Z-.�- -7.............................--.................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS QC,c �O Se-rfC a� S'