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0105 NEWPORT LANE - Health
10 i NEWPORT LANE, OSTERVILLE A= 166 022 o U III 1 4 �I� o o Commonwealth of Massachusetts AP&—�02� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments _0 w 105 Newport Lane . M Property Address pary Ron Casapulla nt Owner Owner's Name �" information is required for every Osterville ✓ Ma 02655 4-20-18 page. CityfTown State Zip Code Date of Inspection a v U ty� 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. General Information S/# ��9 filling out forms -7 7 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation rab Company Name 374 Route 130 Company Address Sandwich Ma b2563 . City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-20-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be"sent to the"system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 11 T14 Vs Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 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: The system was in working at time of inspection. That tank was pumped after inspection for maintenance. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts. y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is Osterville Ma 02655 4-20-18 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).-Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. CityrFown State Zip Code Date.of Inspection C. Checklist 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® 0 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): No design plans Number of bedrooms (Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA _ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 105 Newport Lane Property Address Ron Casapulla . Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.). Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gp ))� Detail: 2016- 55,000gallons 2017-28,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 Industrial waste holdingtank resent? Yes No p ❑ ❑ Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 10-22-15 Was system pumped as partbf the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Tank size Reason for pumping: Maintenance 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 M ❑ Tight tank. Attach a copy of the DEP approval. f ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Newport Lane Property Address Ron Casapu►la Owner Owner's Name information is required for every Osterville Ma '02655 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: No design plans available at Board of Health Were sewage odors detected when arriving at-the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from rivate water supplywell or suction line: Town P feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® 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: 1000gallons Sludge depth: 8 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont) Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 4 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 12 How were dimensions determined? Measured 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank was pumped after inspection for maintenance., Grease Trap (locate on site plan): Depth below grade: NA 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 c Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts ro Title 5 Official Inspection' Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order' ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA t * If pumps or alarms are not in working order, system is a conditional.pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): . If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-2048 page. City/Town State Zip Code Date of Inspection D. System'Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching had 1' of standing water when viewed with a stain line 1' above liquid level. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth —top of,liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction - Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A1-34' A2-3€3' A3-23' A4-34' B1- 16' 3 1— / 82-2t?' 'a✓ B3-21' 134-33' 105 NEWPORT LANE t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is Osterville Ma 02655 4-20-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam.- Check Slope ® Surface water ® Check cellar ® Shallow wells No GW @ 10' Estimated depth to high ground water: f - eet 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: Information at Board of health ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perk log on file with the Board of Health for the lot across the street at the same elevation showed no ground water at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 1 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Newport Lane Property Address Ron Casapulla Owner Owner's Name information is required for every Osterville Ma 02655 4-20-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i r i . DATE: 2195 s PROPERTY ADDRESS: 105 IW2Eti Lane RECEIVED - -- Osterville,Mass .` 0.2655` M'A 2 2--1995:.: Y ------- --- HEALTh TOWN OF BAk. :7,ME --------------------- it I� � On the above dat a 1Inspected the septic c system at the above add ress, j ThIs system consists of"the following: I A. 1 -1000 gallon. septic tank. B. 1 -distribution box. j C. 1 -1000 gallon leaching pit. '- Based on my inspection, i certify the following conditions: A. This .is a title. f ive' septic system. ( 78 -Code:- ) . B. The septic system is in proper working order at the present time. C. Septic tank was pumped for maintenance purpose only. SIGNATURE: 1 r J Name•.----------J.P.Macomber—i------- Company:_J_P_Macombe & -kpI -Snc. Address:_ Box 66 Centerville,Mass. 02632 *-------- P h o n e: THIS CERTIFICATION DOES NOT CONSTITUTE A 'GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SONs INC. Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connectlons P.O. Box 66 CeI�Ierville, MA 02632-0066 • 775.3333. 775.6412 • r SUBSURFACE SEWAGE DISPOSAL SYSTEH INSPECTION FORM Address of property IM MEva ?OCT LAPJC DsTce-V("LC i Owner's name - ; :: . .. .: • : :: :' Date of Inspection ,�•F PART A r, CHECKLIST r,' F s r Check if the following have been done: Pumping information was Health requested of the-=owner;,occupant,, and Board of .•.Yi.•} L. ,.ta'. t '. t; .,I...A - t.-a?.� 4a ! C ...-�-. f _. 'Y. -None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates',duringthatl z: t' period,:. Large volumes:tof.}water have `not`been introduced into the ` system recently or as part of this inspection. l ., . As built plans have been obtained -and.='examiried:A'' Note if„thgy.M'are:=i of available with N/A. The facility or dwelling was: inspect 0111or signs of sewage. back-up. ✓ z f •a 7 t .`::i:.j The site was ^inspected for. signsv_of-•breakout' g' ,' All�•��system components excludin the SAS ,havebeen--located on-the site• _ ... . The septic tank manholes .we.re. uncovered, opened;„and' t2je 'interior of the septic tank was inspected for condition of' baffles`oraatees, material of constructiondimensions,. -depth -of liquids 'depth"'of j sludge; 'depth of scum M..w_.... The size and location of the SAS on the site has .been determined based on existing i•r)formation•„aorzapproximated`-by -'non-intrusive methods: The facilityowner occupants, , . .....=` �, •.'ry . :<: �: . _._. (and occu ants if different' from owner)-„,were- provided with information on the proper maintenance of SSDS A� � y r ai �..w�Aey 6p- lea "oT 1 N .:._ CV $ Z� iZ.£�c.�`� . Nam..,. V-d?-AWL G CG(Ee- o\! L 1..CocK 1?lT 8 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION A FLOW CONDITIONS If residential number of. bedrooms 2 number of current residents ,. ", ., `i garbage grinder, yes or no, laundry connected to system, yes or no 1Qo seasonal use, es,.or..no, .n _._ .. _ U,r .:_ If nonresidential, calculated flow: 3 o. .. ,...,- Water 'meter read r ings, if available., LA�uN >2.21T1orVYS� Last date of, occupancy . , .,.� ... . O UP2L'a44 R '.GENERAL: INFORMATION. .: ,. _ _. ... Pumping records and source of information:� o R C C l�2� D F Pt�u i�Pc rU �. .��a2 015 System pumped as part of inspection, yes or no if yes, volume pumped_ Reason for pumpin g.: Type of system _' Septic tank/distribution'box ,.soil .absorption-*system Single cesspool Overflow cesspool. Privy' ,r Shared system (yes or no) (if yes, attach-previous inspection records, if an )_ Other ('expla 17 A roxim _ate __a e:-.o fa•al ._PP.. . 1---com o- g vents. Date• P installed,,__. n talled . if, kno n. : information: • ;., . W_, Source `of -7 Y r Sewage odors detected when arriving at,the site; -yes no `- _. 4 j ! , f .- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART- B 4, SYSTEM INFORMATION continued -'.SEPTIC TANK: I C-5 (locate on site plan) depth below grade 2:c _ 0 2►5E5 . x . _. , material of construction:. L conc..rete. metaic FRP >" ' "oth'er(expla` n) dimensions:~- ID00 CTALcOu..`1`7AfOK.,..._ .._.:_. sludge -depth L i distance from, ,top .of sludge to bottom of outlets tee or baffles a�Y ._ -scum--thickness _._._. F st . ifs �. . . _._distance...from' to 'outlet �, , r.: .:•: r p `of `scum to- top of : tee 'or-3 baffle ` distance- from bottom of scum to bottom of:; out let.%tee br-- baf fle -,-Comments.:- ... .,_(recommendation -for`,pumping,,"dondition of inlet and outlet tees or baffles, { depth of liquid level in relation to outlet invert, structural integrity., evidence of leaks a . recommendations for repairs:; etc:). « s r r 2 , f%0". i DISTRIBUTION BOX: �oGa� �pfl� tD�� �t�(0CxCA e ,(locate on site plan)-' C�S� :° r ' - depth- of liquid"level above .outlet invert~ Comments:. .. .. (note.-if level and distribution is equal, evidence ,of ,solids carryovers:; "` evidence of leakage into or out of box, ;recommendation:°for "tepairs, `etc: ' ,)'» 777 - •! ` ` °'f ...,...1 f. Barr ..,." .-„ .E+-.. ........... _ PUMP, CHAMBER.. (locate ,on site, plan).....:.._..,.....,...., _......:._...:. pumps in working order Yes or no • , - - . Comments: Crc .-(note -condition of- pump chamber,"'condition of pumps and appurtenances, ;' _ ..,recommendations for-maintenance or* repairs,etc. ) t 11� flR\V6 .4.AA"f ---- ----� Z 10 .,. i „.. - �. }::x9 1 f.., .� dam.._... e. 2 f,.:. �.> i' ;�...7:.'s ,. .:1 e s•� iT`\ Fr , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOIN FORM n F:: PART •.B . ,s ; .; j SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : '� . •.; �; ;� (locate on site plan, if possible; excavation. not required, but may be {,approximated by non-intrusive methods`) > �.: . 4p If not .;determined leaching pits and number leaching ' '' :' _ . a ,. 000 G4c.c�� •'Pl'-f :� f. .. ... chambers and number leaching gall.eriesiand number.:' leaching trenches,, numb.er,-.. length ; . leaching fields, number, dimensions overflow cesspool, number , ' Comments: .- :. (note conditionMof soil=, signs-;of hydraulic,"failure"; ° level 'of ponding,?' con ition of vegetation _.,:..,recommendations. for maintenance_, r,, re airs etc )--- ( _20. ,( use CESSPOOLS "(locate on site. plan) : AsLo_ ELF- L�ih_Gk,.Azo L%,,uz e_utu oVcP-covez' number and configuration% %f= f1P r L.'- depth-top of liquid to inlet invert ;-, depth of solids layer v depth of scum layer dimensions of .cesspool materials of .construction indication of, groundwater,.,,,, �; �: �;:•: f, .,.{{ , inflow (cesspool must ibe, pumped .as part of inspection) ` Comments: .__ .._, _..... _,,_... ___. :.._.,.._ .......... (note condition of soil., signs ,of hydraulic. failure, -level-,!of ponding; condition of vegetation, recommendations for maintenance or repairs,etc. ) • 4 PRIVY: (locate on site plan) t. 1 v ,. materials of construction dimensions., depth of .solids n N.,,...._.,... Comments:—' ,. ._.. ,, n,.,....._..•..w.,. .�•. _. �.,......_ .-�.__w ._... ......: ...;...__ ......., _.._._ _ (note condition ':of"'soil,.signs of hydraulic failure,_-level-.of:ponding;--- condition"of vegetation, recommendations. .for-maintenance or.-repairs .etc.`)"-- rA','.a l�4T;`A ' r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B SYSTEM INFORMATION'LCOAtinued SKETCH OF ,SEWAGE; DISPOSAL= SYSTEM include ties to at least two permanent-'-;ieif erience'-sif ""landmarks or. 'benchmarks locate all wells within 300' i j -•.,.W 7.%'. . .. .. .-. , .1 /, ...:. .. r, .Y :e 4•9.( ,. i.. ,t: ti�,7S.`S. .. i .,• �r V� i ( t ' 3 O I � DEPTH TQ .GROUN DWA.TER .. D S ;:il/C[J Pp iC'T 'G 'w L 1C> depth to groundwater ' method of determination or app oximation: ' i10 S 1 LOB/.,( 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART: � : . ,. FAILURE CRITERIA Indicate yes, no, or not determined ^ (Y, N, .or ND) . Describe basis of determination. in all instances, If "not,�determined'I "-explain`°'why not) ' �D Backup of .sewageL into ,,facility?.,! t .;• Discharge or�pondling'' of effluent 'to' the surface of the ground 'or surface waters? Static liquid level .in the distribution , . 4u ion box above outlet invert. . . i it 0 Liquid depth in cesspool <6" below invert or .available volume< 1/2.`.da ! I flow? y ..� Required pumping 4 times or more in the last year? ~~ number of times pumped,.____-,_--.,-., Septic . tank is metal? cracked? structurally unsound. substantial infiltration? substantial exfiltration? .tank failure imminent? • •. V l ..,....... ..,Y - Is any portion of the' SAS, cesspool or privy: .. below the high groundwater elevation? within -"50 -feet`'- of a surface, water? 0 within . 100 feet . of. a surface water supply or tributary to a surface water supply? within a Zone I of a .public well?+ s 99 within`"50 ' feet of- a bordering ,"vegetated wet a Y, oSAS)-? land orrsalt mar (cesspools.. nd privies -onl no t- the SAS) � , IaO within 50 ell.feet of a *private water supplywell? , ,.. . P , . ���' ,leS:S ,♦ t 'f �_,FF �� 7 -...r' J � ... ,� �.�. � ��.�� .,..� .. o�. � ..f.:... a:_I.;....".... than; 100 1feet but;greater .than,. 50 feet-;:from!, a:private water` ,-, - ---.-.supply well "with "no" ,acceptable,"-water,.qu.alit"._: analysis?.- I'f 'the -well-� j - -has,•been" analyzed-to"be acceptable attach co P . ' ,. ._ .,,._, �_ py..,_of....well._.water -analysis ! for coliform bacteria;"'volatile grganic, compounds.,..:_ammonia.,.nitrogen and nitrate nitrogen`: M ' ! 05/17/1995 13:39 508-428-3508 C.-.O.MM. WATER DEPT PAGE 03 KEY NUMBER <10055 > NAME <SOUZA, CARLTON > B-C 1 B-C 2 B-C 3 B-C 4 STREET P 0 BOX 250 CITY OSTERVILLE ST MA ZIP 02655-0250 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 t METER NO. < 9543> DATE READING CONS STREET <NEWPORT LN NO, 105> 12/31/94 403 90 CITY OST 0 L40 ST LOC 06/30/94 313 9 PHONE ( ) - 12/31/93 304 SQ 06/30/93 250 11 ROUTE NUMBER 14 27 /31/92 239 SERVICE DATE 03/21/89 12 12/3 /92 239 METER DATE 03/30/89 06/31/9 212 52 16 CAPACITY 7 STYLE T10 06/30/91 144 26 SIZE . 1 RATE SCHEDULE KEY PIT PLASTIC X NOTE RR ON FRONT ADDITIONAL CONS 0 ALTERNATE MIN 0 J I I SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D CERTIFICATION . Inspector :Peter Sullivan PE Location : 105 Newport Lane,Osterville Date : May12,1995 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. I have not found any information which indicates that the 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. ' Please note the summary of recommendations as presented in this form. Lastly please note 310CMR:15.302(1)Criteria for Inspection. "The inspection is not designed to provide information to demonstrate that the system will adequately serve -the use to be placed upon it by the new owner. The inspection criteria are intended to I allow for timely inspection to avoid undue delay in the transfer of property." truly yours i eter Su ivan E Distribution: Original to system ownere Buyer SULLIVAN I Board of Heath No. 29733 tIST L t I I i i TOWN OF BARNSTABLE LOCATION /a.s- ,,� �y�c_. .SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING_FACILITY:(type) (S ) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR Owm77R DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: r;. ► d to00 0 /or &eel Pox7' 1, A TOWN OF BAR_NSTABLE LOCATION i-a+4 I-10 .Neva ©; SEWAGE # VILLAGE VS ���•� _ ASSESSOR'S MAP LOT — INSTALLER'S NAME & PHONE NO. .� ��,SC��` �� 17.3G SEPTIC TANK CAPACITY__ N LEACHING FACILITY:(typc) ,*-��A � b (sizel�oOOy� t NO. OF BEDROOMS PRIVATE WELL OR�'UBLIC WAr -kBUILDER OR OWNER DATE PERMIT ISSUED: __— DATE COUPLI.ANCE ISSUED:_^� VARIANCE GRANTED.- Yes -----No � __ f Cv r o qq No... G _ j� F�$. ...20.00... THE COMMONWEALTH OF MASSACHUSETTS BOARD ®F...HEALTH ---- �fi Town ..........OF.....Barnstable ph j4A r _... .. .. ........................................................ Appitratio c for Dtsplaiittl 3 laxk C � � r r tlan rust Application is hereby made for a Permit to Construct ( ) or RepairX(CX) an Individual Sewage Disposal System at 6 Great Marsh Road Centerville ................_........_...................................................................... ............•-----••----••.........................._..--••-----•••-----.........--•-•----•----... Location-Address or Lot No. Susan Lewsen .... _....-----•---.......--•...........................••••....--.............. .............----•--•••-•..._............-•--•-••-•--••....-•-------•-.........................._. Owner Address a J.P.Macomber Jr. Installer Address UType of Buildin Size Lot............................Sq. feet �-, Dwelling No. of Bedrooms.--.. ..3:. ........................Expansion Attic ( ) -Garbage Grinder '4 Other—T e of Building . No. of ersons.................... Showers — Cafeteria YP g P ( ) ( ) Other fixtures =----------------------------- --------••---•--- .............. .-----------.------------- W Design Flow........................................:...gallons per person per day. Total daily flow........................_........._.........gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width.................... Diameter................ Depth...........T.... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area..........;...:.....sq. ft. Seepage Pit No..................... Diameter..... ............ Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test'Results Performed by............................................................................ Date......................................... ;.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ---------------------= -------•-•-•••...................-................... ...------------•--------. --- O .........:.....Sand__:Sc gavel. Description of Soil-------------------------- .._..-------------..----------------------------...----•---••------------•-------••-•------------ V ......---•----------•-•-•-----•--•------•••.............•---..--.........----------------..........--------•--....I..........•-------•-••-•----•....•-----------••------•-•--•--•-....---•--............. -----------------------------------------------------------------------------•-----------------------------•--=----------_------------_..--- ............................z............................. V Nature of Repairs or Alterations—Answer when applicable....... ... 2-1QQ� xa-ilzfi---leash ....................... .................................................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT 1.,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 issued b tWbDoad of healt . Signed.m. v ---•....... ... ......---•--•. ....10/218.9........ ' ' at �• Application Approved BY 'r ........... •----------------- -•-- Application Disapproved for the following reasons---------------------------•--• •-•-----•---------•---•----------------•-•-••---------------••---•._......-•--- -•..................••-••.....-----•--•-.......•-----•••--•-----••----•---------••--•---•--•-----•-•-------••-••---•--------------•------------•----••-•-••----......--• ............................... • Date Permit No.---- ``.''9 ................ Issued-....or --- -•----- � ------ Date No................ ...... FEs.`"'.. :'`fl .'..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town....... ......._OF.....b r.pstahle ........................... ........................................ Appliration for Dispaa,ial Worko Tonstrnrtion rrniit Application is hereby made for a Permit to Construct ( ) or Repairs ZX) an Individual Sewage Disposal System at: �. Great Marsh Road Centerville Susan Location-Address or Lot No. sen •..........................._..... ------------......................... p } Owner Address )..: _R• !:�,�z{ i ' . X_.......................................... •--•.....-----""--•-••......----•'--•---------. Installer Address d Type of Building Size Lot............................ q.S feet Dwelling`s-X No. of Bedrooms...........3.........- ........Expansion Attic ( ) Garbage Grinder ( ) Other—Type TYP e of Building -r••-----•--•----- ......_.. No. of persons............................ Showers ( ) — Cafeteria ( ) W � QI 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 ( ) ►-' Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_.____.-_______----_---. Gzl Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... a ............................... D ----------------.. .nd � Gr �_eA Description of Soil--=---------------------- ..--------- ---------------------------------------------------------------•-----•---•--------------- W ---------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------•---•-_•-'-- U Nature of Repairs or Alterations—Answer when applicable________________________________ 4• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ssued by t e bird health. Signedrp. d.�u/... --------- Date ApplicationApproved BY.................................................................................................. Date Application,Disapproved f or the following reasons:-•---•-------------------------------------------------•------------------------'---------.........------..._.._ ..--'-----•---'------•---------------•--......--•-••---------------------•-----......--------------------'----"'---------•-------'-•------'----'--'-------'--'--"••---•'----------'-''•--'--•....----- Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....'1'©wn....................OF........ a ns aka le ............ . . .................................................. Trdifiratr of Taanipfianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired aK ) CrC ?EY •by...._._.. ...... -----------------------------------------'--•---•----- installer at ...areatVa.r5.h...Road....0.e.' .. ".. -'---....... •'.......... .....•---.. .....r.---•-------- ....----. has been installed in accordance with the provisions of T!TIZ 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated---------------------........................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................._.................... -•------- Inspector.................................................................................... 1 . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rT..QG?r!................OF.....�iaY Y1�S...a e�. ................................................ No......................... FEE. i...P—a ao ... 11t.spaasal Varkii Ounn#r inn amit Permission is hereby granted........ -------_-'-"------••----•---•--------------• •----•-------------•------........----------............._....... to Construct ( ) or Repair-,'( ) an Individual Sewage Disposal System at No......(rent i�la.rvh Road Cent,er r:ille- . ---------------- '-•-•------------•--•-----'-"'•'-••'•'•-'••----•---'-'--------'••----•--•'-'-...----......... Street as shown on the application for Disposal Works Construction Permit No--------_---------- Dated.......................................... ........----•-------•-----------------------------------•-------------------•-----""-•------...-- Board of Health DATE....................... ........................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS Fimic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C9(0 .....T.0__W..("4. .............OF..... i r4G 1J. L ......................... Appliration for Dispatial Vurks Toustrurtion Vamit A Application is hereby made for a Permit to Construct (K) or Repair an Individual Sewage Disposal System at, ..................................... .......................................... L io Add.4e Lot No. ........... ............... ............................................. ....................... Address ... ............. ------------ -------- .................................... Installer Address Pq Type of Building Size Lot--- .........Sq. feet U )OMS......... Garbage Grinder (k1d) Dwelling—No. of Bedrc ..................... .....Expansion Attic VJQ Other—Type of Building NOMM........... No. of persons.......I I.................. Showers Cafeteria WD) Other fixtures ......&.0 -------------------------------------------------------------------------------------------------------------------Design Flow_._._..__...A00.297,51f.......gallons per person per day. Total daily flow_________________aa;lv�) ---------------gallons. 1:4 Septic Tank—Liquid capacity/MrO..gallons Length----/0....... Width...&......... Diameter----ee......... Depth...J�........ Disposal Trench—No. ----C-------- Width.....0............Total Length........0' ......... Total leaching area..__2MOV sq..ft. Seepage Pit No....10-ftAVA Diameter.......40-------- Depth below inlet.......4......... Total leaching area...�.7....sq. ft. Z Other Distribution box ( ) Dosing tank ( .....!�'!.... - Date...........Percolation Test Results Performed by--_---------------A?.1 Test Pit No. per inch Depth of Test Pit....... .......... Depth to ground water.._._!................_. Test Pit No. minutes per inch Depth of Test Pit------- ....... Depth to ground water-----/_V..... -t-I ------------------------i----------------------------------------------------*...".......*............ ............................................ o Description of Soil-----d -_.T.0. 5&JS._<-.-.01.L_. ........ .......................... W - I...-T* '.0 1— - U .................................W .... ' -6-5 Ar7../._Ztt5'=1 .....C ... ....................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------- ................................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with rt,he provisions f TL J"i 1"" 5 of the S t Sanitary Code—The undersigned further agrees not to place the system in :'Is 0 eration uni I Ce t "sate of C ance h been isned by the boar of health. Signed...... ... .................................. ................................. ...... �;" � _ _ - ez'tq-'. 5F __9 4'��_ _- Application Approved By............... . .... ........ ... ........... ------- (�r Date Application Disapproved for the follow�ingo easons:.............................................................................................................. .............................................................................................................................................................................................----------- Date PermitNo.---- ......................... Issued........................................................ Date ij No... Fins..,.1.. ........... + THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r . T r 6 �`a...........OF........ .Z��' .' # `1 ,• ...... Applira#ion for Disposal Works Ton'trurtiun rrmi# Application is hereby made for a Permit to Construct ( ,) or Repair ( ) an Individual Sewage Disposal System at: , c$ eft2 -•.�._! ar � .1�. ..�dl?�Lf ?f?L...............................................t� _..--•-------------•-----................ Loca'o Add or Lot No. � j .. .. v__.: ......... ...... .............--------•---•-- � ................................... er Address Installer Address Type of Building. Size Lot___t_ �V________._Sq. feet V Dwelling—No. of Bedrooms_________ ................................Expansion Attic W.c) Garbage Grinder (/jd). U a Other=Type of Building lc; .__..____ No. of persons______ __________________ Showers (7 ) Cafeteria (�/ ) Other fixtures /tM 1/= --------------•----- W Design Flow___________ _______ S,t;..__ _______gallons per person per day. Total daily ----------------------------------------- Design ...... , .�._____________gallons. 1:4 Septic Tank—Liquid capacity/dCrO-gallons Length..../0_...... .Width _ Diameter----4_________ Disposal Trench—No. Width..... _.•,-_.__ Total Length....... ___::_ Total leaching area___ ,'.___..sq. ft. Seepage Pit No....1-*A b./ f Diameter......./ ........ Depth below inlet___.:__..6t......... Total leaching area...2 %....sq. ft. z Other Distribution box.( , Dosing tank ( ) ~' Percolation Test Results Performed by.................... 1 G` "_c''___.Date___........... as Test Pit No. I.. ,_.minutes per inch Depth of Test Pit ____11__________ Uepth to ground water____Ad �._. (i, Test Pit No. 2___ _' --.minutes per inch Depth of Test Pit-------P '_______ Depth to ground water____/!' _. -------------------••------...........•----••--_-_..__ .._.._.. ....................... ... ---•-- ---------------- •-------------- O Description of Soil'...:': �-'----� `? -• Sr cat&:-- -•-= 1�.---•---- leca IC'� �� -�. •------------------------- x (� yr 4 W -•---••--------------•---------•----•-••-•-------•...----•----------•--=----•-----•-•--•-•-•--•---•--------••--•--•-••---•---------•••••---•••- ----•---------------•---•••-- UNature of Repairs or Alterations—Answer when applicable.............................................................._................................ Agreement The undersigned agrees to install the aforedescribed Individual Sewage Dispbsal System in accordance with . 5 of the State Sanitary Code— The undersigned further agrees not to place the system in the provisions of i i:x operation until a Certificate of Compliance has been isAaed by;t"h'ee bo,�a`rrd of health. /.te Signed--- - a " °� ----------------------•----- Application Approved By-••--•••••-• •- •--- •- .._ c i. - .....: ........... ----------- a- ------- Date, Application Disapproved for the following r asons:.............................................................................................................. -•---•---•----------------•-••----------------------------------------------------..........---------....__....---------------------------...---•--------------•-------...-----...................... Date PermitNo......1?�_... ........................ Issued--------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......I,,a.. ..:..:...OF.....:. .Gr --el................::... Trdifirat a of f ompliattrr"'. THIS IS TOA.C�ERTIFY, at the Individual Sewage Disposal System constructed,,,'�,/ ) or Repaired ( ) ,. tff b1!- .?r c !e ' -----------------•--••--•-- -- -----______--------- _____-------___________----------- InstallerJ `� at-------------L ------ = � - t'` G�' ------------ 'y � --•---------•----•••-•----•------•---- has been installed in accordance with the provisions of i i i"�' of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... . .... dated. .......:................................... THE ISSUANCE OF ,THIS CERTIFICATE. SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................y�.-_7.-.. ..�j._....._............ Inspector.. _t-. : THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Disposal Works Ton trudion famit Permission is hereb ranted:____ -- Y g "- ' t - 1 to Construct (X�) .or Repair ( ) an Individual Sewage Disposal System '¢"� at No.,.,___._._ ._. .cy�+�^ ���_ /_-Sw:�_ct:4,� 4 41:t /Sk�c,F.°�� ..........H(J 7..................................................... �� Street as shown on the application for Disposal Works Construction Permit No._�rO ............. Dated............................................ --------------------------------------------------------------------•----------•--------••-----•--•==--- Board of Health DATE................................................................................. FORM 1255 HOBBS &`WARREN, INC., PUBLISHERS - - ...., ,-z LoTSS LOT j � IaO• 5y I qr _Sa E OF S s G� DAVID P. �yG MARIANO o ^� I Cnkto' - P) c3 CIVIL h LEACH PIT i IOI No.31115�0 �GISTEa f� w 50,1 Tei� Ak�Zfs`P/ONAL I coo `7 i-- .,� S �Tru1K Tsorc�rrtl !I LOT `7 o \ a7 . to l00.5 0_ . 3 \ fin LLj T. T LoT 4 0 /0, 4 54 S � I � d ZoN E RC dill Assvi-+� Hof A��+ Pio frc�io.•i Pe•� °I� �t oor u1 �r�-�f� E°�t�orM4.10c REF 738 EXISTING S?C.-T E-z-VAT!ON ox0 r` y� E'xISTING C0%-r0!'R --- O — t PAULA � CERTIFIED P T PLAN k, LEVY '' �iN :'DEL' CLEVATiO'a .• ( _ -=�-_" =1NLSHED CC.i jOr: ? -- !� �.I oo T O STURBRIDC-�E .�R1VE XTL': The location of any existingu u _SIT ••e gel ls, or other ut i l i t ics s'-own on this i, 11� Prox- 1 �r`�. �Os-r-ErZ,VI�Lr) Mate only as dCtermined from records and/or verbal information. The contractor is re ;onsible for the ' ���"ST�B�� verification of *h:: Axisting locations irn the field; SCALE= 'LI�..�i DAT< < `1 I°I. 8(0 LEVY & KDREDGE ASSOCIATES, INC_ CLIENT FAVISIDE I CERTIFY THAT THE PROPOSED , JOB NO. , l 7li BUILDING SHOWN ON THIS PLAN ENGINEERS- LANDSCAPE ARCHITECTS CONFORMS TO THE ZONING LAMS PLANNERS- LAND SURVEYORS DR:BY,, A'A.M OF mill S14 e M S. e 8 9 V.I. NA0N ST';PELF 4CH. By 411 -w* L�NT' kVIL.CE, ISHEET-1 OF 2 DA LAND SURVE OR z �. 20 FT. MI.-V. /F E/ -HeT THE SEPT/C TANK OR ` •� _EACH/n/G PIT A.tE MORE TNA."/ /2BELOJt/� /D Pr. MIN. �RAOE� A9 24'O/.4METER CONCRETE COVER 4•PYC p/PF 'SHALL BE BROUGHT TO GIrAOE.��"+N EXTR�i co)vG/tCTE MIN. P/TCl/ /aE.4Vy CAST IRON CoVF,T SHALL DE USEO •�•. _ CODERS �B'PE,Q FT. /F/N OR/VEJ•t/A Y 2 MiN. C01YCRAF776' G AOE COVER C'L EAN .r SA N AP BACA LL �. L19010 Lf_YEL 4 %RON p _ 2'LAYER /PE MIN.P/TUI/,'t I4•PER IT, l Cam_ GAL D I ST, o• • • • a • • ► >•��' WA SHED S7ONE SE!-"T/C TANK . . 1 1 � i • •u BOX n + e e e � • . • 1 • � .•� •• i 34 A f • v • I e DE'v'r • I 1 • v e WASAF.0 STJNE Y.:i �CA.SX2.Sa 4.7l. 3 GPo � . v 01 f • • • • 11 lea • � � � 1 1 • e • • • e 1 o p o ' 78•S GPO ► • e • • • 1 1 p • v PrEG45 T SEEPAGE IAIVZA'a' ELEVAT/o/Ys D. • ,• • 1 . . . . . 1 . `p P/T OR EPU/V, . 599.8 :z /NY,--RT AT QU/LD/NG FT 6_FT PIAM. INLET SEPT/C Ts}NK L?FT 10. FT O/i4M. C SEE T.4BUL4TlOA�) 0UTLF7-SEPTIC TANK 96.f3 FT. /NL�ETD/STR/BUT/ON BOX FT. GROUND 1�4TER TABLE SECT/O/V O F OdTLETO/STR/BtIT/ON BQX_L(o,.,FT. /NL6T LE'ACN/NG .-/7- ,'L 'r SEWAGE O/SPOSAL SY.ST&M TABULATlD/V LEACH//VG /a/T SCALE : %s~ _ /- 0" D/ME/VS/ON A 3.31 FT. DES/G/V CfZ/TER/A 0/,414)V5/0 AI 8— P FT. NUMBER OF BE.(>ROO/y,S _FT. 6A6&Fv/SoOs,4. 6/,y IV6AIE_ SO/L LOG TOTAL EST/MA'/E� FLorV 33 L SOIL TEST */ SO/L 7Z75T,*2 SD/L TEST NUMBER OF.LLrACXtNG 40/7-3_ / S/OE LG'AG'H/NG PER P/T. =LDS_547 F7 fa�_ � � �Z ez.e 22 8 2 i , , _ BOTTOM�L,�rgG'N/NG P� P/T .7 S O -2. RESULTS h//T/VESSED BY_ Ti NIG�EO e R �=—$Q. FT. Toa E SOBSCI Tor, jU2�O1L 1'el COL AT/O!V ceATE At/ LZ M/NtI/NCN TOTAL LEACH/NG AREA FL',tCO LAT/ON RA7-'- RESERVE LEACHING A�ZEA ZfoZSQ. FT. Z�-lI' FA tj s'd/L TES �o e.wl� P. sq��\' jFr�p MEDIu.t\�l o M-ARIANO rn'1 S�1J v /.0T .5/6 �.�Irnile,�P/D cr,E Ael VE u CIVIL � F 25Ae/ Ni.31115 c ^ LEVY & ELDREDGE ASSOCIATES, INC. �or�"lSTFQ Fs z �`I til.�i,4�NSr.,CEn/TF_�U/LG�,Mf}ss_ NO GROUN[7 YNi4TER ENCOUNTE.e�O el-/ENT:g j�g PRTE : 9 /9 e6 �J GROUND 1wATER AT ELw _ .JOB NO•' %67(J