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HomeMy WebLinkAbout0459 MAIN STREET (OST.) - Health 459 MAIN STREET, OSTERVILLE A= 164 014 0 Commonwealth of Massachusetts I&q- 07y Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 { �} page. City/Town State Zip Code Date of Inspection c Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information /,,l►. �qs-g filling out forms on the computer, use only the tab Sean M. Jones Key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. Co Lane � Companypang Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/13/2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 9 - Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 459 Main Street Propert✓Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Ccmments: The property located at 459 Main St Osterville is served by a Title V septic system consisting of a 1000 gallon septic tank, and a precast leach pit. The system was found to be in proper working co-idition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined' (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A.metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form j; Q Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/T:)wn State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". _ Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ E 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? E ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ®I ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 459 Main Street Proper.y Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Oster./ille Ma 02655 7/13/2019 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms (actual): 2 D,=SIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd. Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/user Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., 459-Main Street Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 7/13/2019 page. CitylTcwn State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system . ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: original system 1974 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 459 Main Street V Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Tcwn State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: Z concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon SI'udge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc-rev.7/26/2018 Title 5 Official.lnspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction:. ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterv'Ile Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Da`_e of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Deoth of liquid level above outlet invert N/A Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pu-nps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): " If'pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If.AS not located, explain why: Type: leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Ostervil,Ie Ma 02655 7/13/2019 page. Cityrrowr State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of a precast leach pit. Pit was found dry at time of inspection with a stain line approx 3' from bottom. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is Osterville Ma 02655 7/13/2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C> �Z 3 6 3 2- r (33 V 2 l5insp.doc•rev.7/26/2018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurlace Sewage Disposal System Form -Not for Voluntary Assessments , y 459 Main Street Property Address Edward& Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® 'Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑� Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 459 Main Street Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 DATA 4 :7l30196: PROPERTY ADDRESS: 459 MiEh Street. ' ' �t � 0sterville ,Mass . 02655 jib 1' On the above date, 1 inspected the septic system at the above address, " This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -1000 gallon leaching pit . Rased on my Insoection, I certify the following conditions: 1 . This is a title f'iye septic system. ( 73. Code- ), 2 .. The : septic system is in proper working order at the present time . 81GNATUW7: Name: J. P. Macomber Jr•.. Company:_J• P,Macon�ber & Son—inc .. ...... ....... Cent e'rvi11e LMass_:V02632 Phone:---SQBzZi�3338------ I a i THIS CERTIFICATION.' DOES NO1" A GUARANTY OR WARRANTY AT M!M� JOSEPH P. MACOMBER & SCAN, INC. "Yanks-Css6pools-Laachflelds Pump*d & Insisile4 Town Sewer Cormoctions P.0• Box 66' Centerville, MA 02632-0066 775-3338 775-6412 . Commonwealth of Massachusetts Executive Office of Environmental Affairs k �i%vl onmental Protection I!am F.WeldG000 Trudy Cox* Arpeo Paul Cellucci s. s"I David B.Struhs It Governor Corrur>Laiorrr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Proporty Address: 4 67W Main Street 0 s t e r v i l l e ,Ma's . Address of Owner Box M Date of Inapeotlon: 7/3 0/9 6 (If of O s t e r v i 11 e,Mass . Name ofIuspeoton Joseph P. Macomber Jr . 02655 Company Name,Address and Telephone Number. J. P.Macomber & S. .n Inc Box 66 Centerville ,Mass . 02632 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: I �Paaaes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails / �.t-'�-J Inspector's Signature �,� 1 i`/ Date: e The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSThi PASSES: G� I have not found any information which indicates that the system violates any of the failure criteria'as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B] 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). DescriW basis of determination in all instances. If"uot determined",explain why not) Li The septic tank is metal, cra:ked, structurally unsound, shows substantial infiltration or ex0ration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Winter Street a Boston, Massachusetts 021W * FAX(617) 556-1049 a Telephone(617)292-SW � A e� Printed on R"Ied Paper V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinuod) PropertyAddresa: G,59 Main Street Osterville ,Mass . Owner. Debra Cochran Date of Inspection: 7/3 0/9 6 B)SYSTEM CONDITIONALLY PASSES (continue-d) .A I 1`i 'Sewage backup or breakout or huh static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four tim^;i u 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 Cl FURTHER EVALUATION IS REQUIRED BY TILE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: L Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a rurface water supply. 2,_(1 The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) O/T'9HER (revised 11/03/95) 2 RFACI' S,WAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) 459 Main Street Osterville ,Mass . 02655 Owner- Debra Cochran Date of Iu:,p '.'i .. 7/30/96 DJ SYSTEM FAILS: u I have deter it etn ed that the syat violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determinnticn is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. /IZI Backup of sewativ into facility or system component dice to an overloaded or clogged SAS or cesspool. f Di:ci Lae u, of elTlueni to the surfac. .: the group! or surface waters due W -t overloaded or clogged SAS or ces,U pool. 4&1t, Static liquid level in the d:stribu,.ion above outlet invert due to an overloaded or clogged SAS or cesspool. ki,io, v'r r Liquid depth in,c"spool is less tlLui G" below invert or available volume is less than 1/2 day flow. it %. Required pumping more than 4 tirues in the last year NOT due to clogged or obstructed pipe(s). Number o times pumped 7 Any ; _:t:at of tine Soil AhaorT-lion System, cesspool or privy is below the high groundwater elevation. At;v r .i:. ,', of a c"spool or privy it within 100 feet of a surface water supply or tributary to a surface water supply. Any N.tion of a ceaspoci or privy is within a Zone I of a public well. r Any pertio:i of a -.,spool ur privy is within 50 feet of a private water supply well. N''I{ 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 arur_lysis. 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. El LARGE 9Y9TE',I ?.'_.:.. . The follc— _. .arse syat.t::s in addition to the criteria above: The cyst-m ee, with a d,:aign flow of 10,000 gpd or greater(Large S st,m) and the system is a significant threat to publichealth and m::fEty artd the enviroianent because one or more of the following conditions exist: IVA tl;o syst1-:m is within 400 feet of a surface drinking water supply tk,e i vvitldn 200 feet of a tributary to a surface drinking water supply ltJr� ? in a nits; er, acruiitive area (Interim Wellhead Protection Area(IWPA)or a aunppod Zone II of a public The owm r u: ,,...._... juum ac, ; :�*ing the oystcm"d futility into full compliauc. wiLn t..., t r t,vLtrnent ptogra::. requirements of 314 (11 ''' 14.00. Plecoe consult the local regional office of the Department for further information.. (revised 11/03/95) 3 PropertyAddreBs 459 Main Street Osterville,Mass . Owner. Debra Cochran Date of Inspection: 7/3 0/9 6 s Check if the following have been done: ` ,'_Pumping information was requested of the owner, oagVpant,and Board of Health. ,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection, ZA, t plans have been obtained and examined. Note if they are not available with N/A. The facihty or dwelling was inspected for signs of sewage back-up. 2The system does not receive non-sanitary or industrial waste flow .L The site was inspected for signs of breakout. )1v _A11 system components,excluding the Soil Absorption System,have been located on the site. j�The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for oondition 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 existing approximated by non-intrusive methods. information or facility owner(and occupants, if di&rent from owner)were provided with information on the proper maintenance of Sub- surface Disposal System. (revised 11/03/95) 4 l� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART C SYSTEM INFORMATION PropertyAddcnha: 459 Main Street Osterville ,Mass . owner. Debra Cochran Date of Inbpeotiuu:7✓30/96 FLOW CONDITIONS RESIDENTIAL• Design flow:. --gallons 14-�' Number of bedrooms: 9 Number of current reskents: L Garbage grinder(yes or no):=S ``jj, Laundry connected to s:stem(yes or no): !.�7 Seasonal use(you or no-.:,I Water meter readings, C available: ��G/ '� :✓Ij/ - ���. (ili Last date of occupancy: COMMERCIAL/INDUSTRIA.0 Tyke of establishment:_ tilq Design flow; cns/day Grease trap present: (yes or no)1�`/t Industrial Waste Hoidin;Tank present: (yea or no)&)-q Non-sanitary waste discaarged to the Title 5 system: (yes or no)_ Water meter readings, if,available:_ 414 Last date of occupanry: OTHM' (Describe) =/a Last date of occupancy: / GENERAL INFORMATION PUMPING4ECORDS and source of information: System pumper as part of inspection: (yes or no)X-115 If yes, volume y.umped: Reason for Pu-Lr.pin& TYPE OF SYSTEM . — Septic tank/diatributiati-)mrJsoil absorption system 4.0 sib co"pool Overflow o&"pcol A)6 Privy Shared system(+es or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE o'all components, date in.:talled'(if known)and source of information: Sewage odors detected when arriving at the site: (yes`br no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) ropertyAddress: 459 Main Street Osterville ,Mass . r wner: Debra Cochran ate of Inspection: 7/30/96 ` EPTIC TANK:_Xw lo�w ovate on site plan) rr rf epth below grade:_%r aterial of construction: V concrete _metal _FRP _other(explaiii) imensions:_ Mudge depth: istance from top of, dge to bottom of outlet tee or baffle:.- O.,-cum thickness: istance from top of scum to top of outlet tee or baffle: _ istance from bottom of scum to bottom of outlet tee or baffle, omments: ecommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid level in relation to outlet invert, structural �ricy, evidence of leakage, etc.) Pump tank annualjy;� Garbage dislo9 a]nresen -1-hIgLand ou&t` tees are in place • The septi is 5t94Ctural l y snund • No pai_re nPedoi�t,�t.ha REASE TRAP. 4 fie ovate on site pian) epth below grade:(i� aterial of constrn.jr1i6ri—_.oncrete _metal _FRP other(explain) i� )imensions• cum thickness: istance from top ur scum to top of outlet tee or baffle:_Al istance from bottom of Crum to honour of outlet tee or bahle:AfA r .omments: 'ecommendation for pumping, condil—rl of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural Iegrily, ev�ence of leakage, eiL 5 IV La.u•��r'S evised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pr.;, r Add,-ess: 4.59 Main Street Osterville,Mass . Owner. Debra Cochran Date of Inspection: 7/3 0/9 6 TIGHT OR HOLDING TAM::A J f/e (locate on site plan) • Depth below grader Material of constructioa concrets_metal_FRP_othsr(esplain) A24 Dimensions: _ Alt9 Capacity: ' "Dons Design flow: ons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) �+ Cn�2t.rlN1G'7�S . DISTRIBUTION BOX-AIV(� (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER: t444' (locate on site plan) Pumps in working order:(yeo or no) A Comments: , (note f°ndi ' of pump chamber, condition of pumps and appurtenances, etc.) _f.�3i1�1*ps ipli)TS' (revised 11/03/95) 7 0 " ,` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ProportyAdd— 459 Main Street Osterville,Mass Owner. Debra Cochran Date of Inspection: 7/3 0/9 6, � SOIL ABSORPTION SYSTEM(SAS):/ AW44, AP �' 117 (locate on site plan,if possible;excavation not required,but may be approximated by non•iatrusive methods) If not determined to be present,explain: Type • leaching pits,number, leaching chambers,number .•�i' leaching gallerlse,number leaching trenches,number,length: G leaching fields,number, overflow cesspool,number: --) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition 9f.vegeta ) Medium and;No si ns of hydraulic failure or ponaing tatTon is nnrmpl - No repairs needed at the present ime. CESSPOOLS: �t (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: A24 Depth of solids layer. A,1 Depth of scum layer. 11 Dimensions of cesspool: AW Materials of construction: Indication of groundwater: T 1 inflow(cesspool must be pumped as part of iaspection) Co n+,(note oonditiQg soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: ry— (locate on site plan) . Materials of construction: Dimensions Depth of solids: Com�ents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,eW.) (revised 11/03/.95)� g ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L'_SPOSAL SYSTEM: include ties to at least two permanent references landmarks, or benchmarks locate all wells within 100' 8enterville Osterville Marstons Mills Water Company 428-6691 DEPTH TO GROUNDWATER depth to groundwater • 1 . mQtkQd�of d^ t ihion, -or 'aproximati�op:. . ` e • . x+ a ''ina'tall ed. - r:'- ~_z�+'►=.Ire w:�,•+-�ssa•�., ..� w---- ..O 4 •b. .r.r - � . i6 _ l5� .r+d�"r 't• SIC _ (r�V JCS ���• 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. June 8, 1995 Acting Director of the ion of Water Pollution Control �a•mnr e-nrm—ry•%r 4m-e r�*v".r .Yrm n•rses wwr.ewm rnm%w r*o'esrertesn •rtr'na�r-.trnr.inr.r-••�;. TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �J �•••rrh-r•••:: --..rr.••.ernmr.n•n:rnrne•yes+r,m•:terrrya+-tirme�m+rnrt-•rn+r+eracv�s r.mn�esrrrtrasvrr'+rr•rw.J+•r►•rr•tr•�r•-.•� -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 459 Main Street Osterville,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Debra Oochran PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & S6'n"Inc. Box 66 Centerville,Mass. 02632 COMPANY ADDRESS J.P.Macomber & Son Inc. Street Town or City state LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 790 - 1578 m 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: ' XXXXXXXXXXSystem PASSED The inspection which: I have conducted has not found any information which indicates thatithe system fails to adequately protect public health or, the 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 jiublic 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 8/10/96 ' ' One copy of this certification must be provided to the OWNER, the BUYER ( where applicable) and the BOARD OF HEALTH, If the -inspection FAILED`, thle owner or operator shall upgrade ' the system. within o'ne year of the date of the inspection, unless allowed or required otherwise as provided in 31.0 CHR 15 , 305 . --- - gar o TOWN F BARNSTABLE � � LOCA i IG t SEWAGE # VILLAGE ASSESSOR'S MAP& LOT AME&PHONE N� r ��� " SEPTIC TANK CAPACITY LEACHING FACILITY: (type) G (size) NO—OF BEDROOMS 0 BUILDER OR ��W1" �� PERMITDATE: 5;;L *72fK DATE: ��"�� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility JFeet 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 Leachin Fa 'lity(If any wetlands exist within 300 feet f leachin f Feet .Furnished by 1 i k r�� . 0 e A T ION SIWAGI PERMIT NO. Main Street , .(A-164-14) 74-125 VILLAGE ' Osterville INSTALLER'S NA IRE i ADDRESS Alfred Fuller � UILOEIII OR OWMER Mary Page Rand or Thomas 0. Cochran, Jr. ® ATE PERMLT ISSUED 4/3/74 DATE COMPLIANCE ISSUED 6/4/74 r - �� � ,y g LOC-AT_I.O_t�lSEW_ PERMIT(�-IJ O.. Eu 5-U LL_D E-R S-KL&-M�_ --�- -D D R E-SS Dl�►TE_P_E_R_Iv�1T-1_SSUED������_ _ _� �Q dQ �b\) No.. �... .� Fkl....... ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H�EL1_p`L}t T H d4ell - ---------------OF........ �j Appliration for 13ityusal Works Tonstrnrtion Vautit Application is hereby made for a Permit to Construct ( ) or Repair (P-ran Individual Sewage Disposal System at: Li ...._.. � At--------------l� v.� --_------------------------ --- tior�ddr �J��,'/�J �` or Lo No. � ------------ OwnerIV dress Installer Address UType of Buildin Size Lot----- ,f ...__. ------.S�--feeC Dwelling No. of Bedrooms............ ...........................Expansion Attic (dl/P Garbage Grinder ( !o aOther—Type of Building ---------------------------- No. of persons............. Showers ( ) — Cafeteria ( ) d Other fixtures ------------- -------------- = -----------------...........------------------------ = ----------- ......._ W Design Flow------ ____d_-____-__---•-- allons per person per day. Total daily flow...._.__._.t�.e�.---- -_-_-----gallons. WSeptic Tank f Liquid capacity/allons Length................ Width----:. ......... Diameter................ Depth-_--..-..-'-___. x Disposal Trench—No. .................... Width............ _ 1 . ,jotal leaching area--------:____----___sq. ft Seepage Pit No......../---------- Diameter... .•.... ept�i BeloW nlnlet.................... Total leaching area------------------sq. ft. Z Other Distribution box (' ) Dosing tank ( ) sr', koG! )�4 /$/?f- aPercolation Test Results Performed by--------------------------------•---------------------------------------- Date---------------------------------------- Test Pit No. 1................minutes per inch. Depth of Test Pit.................... Depth to ground water--_._--___--__-__-_---_ tT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_.____.._...._-.-_-:. W ----------------------I---------. .. -- - - - --- ------ - _ O Description of Sail----------------- �_ ��... d - - - (xj =--------------------------------------- W U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: --------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sew e Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—. he unde d f rther agrees not to place the system in operation until a Certificate of Compliance has been ' s by e o ealth. -- --- -- ---- ------------------______----.--.--- ------- Si ��� Da Application Approved By------- _ . _ ........ .._ __ ,_ __ c XX;X V�-- Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- .................................. ........................................................................................................ --------------•-------. -•-••-. -------------------------- Date PermitNo.....•-•------------------------------------------------- Issued.-- ---. . ..... ............ Date `fi �� —• No.---- ------ FiR....... ......i.w"..�... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH GW. .... ......O F......... - , ppliration for Disposal Works Toustrurfioat Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (y°ran Individual Sewage Disposal System at: � __-- - --- - -- -•--------------- ---- -- -Lot"No----------------- ------------- �yp� �Oj JG� tioddreLP����!(J/���'/Q s1J ��t gc���� t ,/''�*�- or I.o/t 1No. �> �--_-- ---- ..______..9._5 � _______ .CYJ _.-... �Y..aY_,0.................. __.. '_!.[.�:�!:._____: Py...J..._..,C!:.o "e?:$.�I�_ ..._...._........_._ Owner Address ---------------------- ------ ----------- Installer Address Q Type of Buildin Size Lot--_.— 0___ ___ V Dwelling yxo. of Bedrooms------------f _____ _____ Expansion Attic (/� -p Garbage Grinder &'� aOther—Type of Building ---------------------------- No. of persons............................. Showers ( } — Cafeteria ( ) QOther fixtures --------•---•---••------------------------------•------------------------------------•--•----•-----------------•--•-----•------------------ W Design Flow-. 1.4 �Wl gallons per person per day. Total daily flow...........'P"" ._. _____.___gallons. WSeptic Tank Liquid capacity. gallons Length................ Width--------------.. Diameter---------------- Depth---._._.....__- x Disposal Trench—No..................... Width ---.�n �� .Wotal leaching area-------------------,sq. ft. Seepage Pit No........�.......... Diameter___ ___________ ep e oy inlet._.___.__________._. 'total leaching area__-......._.__....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------------- Date.------------. =--------------------- ,� Test Pit No. 1..................minutes per inch Depth of Test Pit.................... Depth to ground water----_-----_-_-____--._-. "tom Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------.___------__- - ----- (---------------- ----- '� Description of Soil------------=-----0. --- - - -c -- --- / x �`"`�$ V -•---•-------------------•••••-•......--••-•-`--------•---••----- W U Nature of Repairs or Alterations—Answer when applicable.--------------------------•-__---_____-____-'•_-__-•-•.-_---.--__------.-..._-__--_--___---._. -----------------------------------------------------------------------------------------------•-----------------•.......-----...•---•------------•--••-••••--....-----------------------•----•------ Agreement: The undersigned agrees to install the aforedescribed Individual Sew e Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The unde d f rther agrees not to place the system in operation until a Certificate of Compliance has been i�s�byy dffe - a�`d�of ealth. A licatibn Approved B Dat PP PP- Y te Application Disapproved for the following reasons................................................................................................................ -•---•---------------------------------------•-------------------•-----------------------••------------•-----••-•--•-•--••-----------------------•---•-•------------------------••-------•---•--------_.. - - � - - Date PermitNo......................... ..._........... Issued...................... -------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH 7f OF......... %LWr#if it ate of f911ntpliattta TH T19 TIF at the Indi • aL Se g Dispo al System constructed (4' or Repaired ( ) ♦ 1 er at........ _-=--- •-------- -- -- l has been installers in accordance with the provisions of Article XI of The State Sanitary Code s de ribed in the application for Disposal Works Construction Permit No.........1_--`+G--_�—_-___•__--___ dated------- ___ 'T . 1.............." THE ISSUANCE OF THIS.CERTIFICATE -SMALL NOT BE CONSTRYED-Al A GUARANTEE THAT THE SYSTEM WILL FUN 'I°ION A I, F TORY �/ DATE. •• -•----- ---- -•-- .... Inspector = THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH. . ................OF....... ... At -1k•1: ......_.........................----- ��y ... No......................... q�pgy .� } *4 y} FEE... 10-- it Permissionjereby granted ;r.• ---- ••---- ---------------------------------------- = to Constru ct ) or Rep'2' ) an vidual wage D' osal Sy item at No. C1..�.�.4 -•- --- . > Lr/ *�,�� StreY as shown on the application for Disposal Works Construction Per t No..._ ,.._.____ Dated... _:/. __ /` DATE...................... e Z --------------------------------- FORM 1255 HOBBS & WARREN, INC:: PUBLISHERS s^1;.. .................... TO THE-INSPECTOR OF BUILDINGS: , The undersigned hereby applies for a permiViflaccording to the follo*wi.ng information. Location .......A'1_11.:Ivk ....1 051-1..............1�� ............�v................................................................................. Proposed Use ....... 4F .//: .........................�.:................. , .................................................................................... Zoning District ........- ........ ......e?..... Fire District ..... 4� M26 ........ . . . Name of Owner ......&............................Address ... .... .. ... ...... Nome of Builder ... S ......Address ..... .......A V................ Nomeof Architect ................ ..................................Address ................................................................................4 Number of Rooms .............3...............................................�.Founclation .......... oV Exterior ..................Roofing ............ /I lel�...................... ..... .......... .......... - ............... ....................... Floors ........... .....................Interior Heating ..6-11Ah ':............................................................Plumbing ............. ............................................................ . .......................................... Fireplace ............. ........................................Approximate Cost ............... Definitive Plan Approved by Planning Board --------------—------------- --------- Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD OF HEALTH 3 TR E E7_ 4 so_411 A I hereby agree to conform to all the Ryles and Regulations of:the ZTowno rns Vra ing t above construction. Nome _...71P............ .... ............