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Home My WebLink About0022 OLD SALEM WAY - Health ��. � r ,�" -- t r a v - - 4 3 ASSESSORS MAP NO: �h �r r No:.....� . _... : .J PARCEL N0: :C,��A� F�$..........��et....:... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF , HEALTH ..........................................OF........................................------------------------.............--•--•-----•. Allp iration for Dispn�a1 Works Tongtrnrtinn ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..............t=,a 5 f►.4. � ! !'!i< S .P!/�Gam= 7 3 ..__..._... -------------- ----------•-------•----_.... -•-•----••-•----................----•••. �Q Location-Address or Lot No. _ .......................... .- 4R-� ..... - .. ...... .. . Owner Add C �l �r a --••--......��✓' '... .(,_k..•^......................................... .........*-•---V- ��7fY�7.U.1{` _......1 Installer Address d Type of Building Size Lot____:z _it.. ....ST.—Leet Dwelling—No. of Bedrooms................ .........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures ......................... ...••. . W Design Flow............................. ......gallons per person per day. Total daily flow---_33!?......... ....................gallons. WSeptic Tank—Liquid'capacity/A;AP..gallons Length..X.4 Width..�`%o�__ Diameter........-...... Depth. �-1"-.. x Disposal Trench—No- --------- - ----- Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-----------/------- Diameter.........,........ Depth below inlet.....G.......... Total leaching area..?. ......sq. ft. Z Other Distribution box (it Dosing tank ) ~' Percolation Test Results Performed by.,ff__L1.. f� ._.4vtm4-z �............... Date_./ .'_ .-__ ........ ,aa Test Pit No. 1----- ......minutes per inch Depth of Test Pit____Z.z.?y_.. Depth to ground water..__:'............... Test Pit No. 2.......9......minutes per inch Depth of Test Pit...... Depth to ground water.......I............. •--•-------------------------------•-----------------------------------------•--•----••••---•.-•----........................................................ 0 Description of Soil...x _J.'•.v.^'1....$�A -----------------------------------•---...---------•-•-•---------------- W -----••---•----------------•------•----•-----•••------------•-•--•--•--•---•-- •--••------•------•----••--------•---------------------•-•------------•••-------•--•-•----••-•-••-•---•--••--••--.------ UNature of Repairs or Alterations—Answer when applicable............................................................................................... ...................................................--................................................................................................................................................... Agreemen.t: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE y g g p y S o4 he State Sanitary Code— he undersigned further Fees not to lace the system in operati n}until er to Compliance has been issued y the board of healt . A- 4 /� Signed...............--•- lR/l�X.._..... ( ac .L� Apication Approved By--•---------�,�✓-... .......n.. ---•--•------------------ ..........�-^ P�---- V " Date Application Disapproved for the following reasons----------------------------••---------------------------------------------------•-----...-•---•-••---........... ....-•---•-----------•----•-•-•----------------•-•---•-•-----------•------••--•--•••._....-•-•--------....-•-•---....•---•----••----••••----•-••---•-----------•----•......---•---••-•-•--••--•-•------- Date PermitNo.......... ..................... Issued....................................................... Date Pr No...... 060 FEs.........Z,.r-......''" THE COMMONWEALTH OF MASSACHUSETTS BOARD . OF HEALTH ........................O F......................................-.................................................. Appliratiun for Disposal Works Towuur#ion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: Location-Address or Lot No. — Lam. --...1.er.....f .... .................................................................................................. Owner I- - Addres ') i W � Z.U.4-C6I.-----------------------------------•----•- ---...--- �.�.� ��A:(.L�'�`�1(��_�E' ..=--- Installer Address dType of Building Size Lot......Z6__4c_...__..Scl.- et Dwelling—No. of Bedrooms.............. ..........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures .................................. _ W Design Flow.............................;5.�._..__..gallons per person per day. Total daily flow___ 0................................ WSeptic Tank—Liquid capacity&- ...gallons Length. -_A .... 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 ( ) _ 1-4 Percolation Test Results Performed by l ..! !`Z �r.._ =_!✓!.K'��`✓l................. Date.Z .-Z 2_.'. _....._.. Test Pit No. I.....2_------minutes per inch Depth of Test Pit.... =_ Depth to ground water_.___"'............... fit Test Pit No. 2......G.......minutes per inch Depth of Test Pit...... Depth to ground water..................... a --------------------------------- --•--••••......-•....-- ---------------------- •-•••-•••••---------------- ----------------------- ODescription of Soil... `�`'`�- ('.` ,3..........fig;'��•, �J�. �l�a.✓��±----------------------------- -----------------•-----------•------------. x W ••-••---••-••---•----- UNature of Repairs or Alterations—Answer when applicable............................................................................................... -•---•-•-•.•---••••---•--------------••----•----•••--•-•-•••-••-•••-•-•--•-••-------...•--••••-••---••-••-••--••••------••••-••-•---•---••-••••----•---........••---•-----•-•-••••••-•-------------•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE p 5 of he State Sanitary Code— the undersigned further agrees not to place the system in ' ri operat until er to f ompliance has been issued y the board of heal•h. r Signed. ,__ � t:C�:l.� '. .•---- -r C . ate Ap lication Approved By............... . . ----..Y)..ca,.M h ----•----- =� Date Application Disapproved for the following reasons---------------------------------••--•----...._....--•-----------------------•--•-----•------......--•...--•---•. --.........•------•--•••-----•-•••---•--•-----•---•-•-•-•-•-••-•--•---•................•••..........••-•---••---•--•-•-----••-••--•-•---•-------••••-•-•••----•--••-------•-----•-----•-•---••••-------- Date PermitNo.......... .................... Issued-...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. .........OF........ -s etc,a ................................... Trr#if iratr of Tontplianrr THIS IS TD- RTIFY, That the Individual Sewage Disposal System constructed �>.-) or Repaired ( ) by-•......(y ••......�._ ��. ...............-•--•-•---•----•--•---...----------...-----...----•------•---•-•-•-------•-•-•------•---•--------•--................---•----•----•-- n Installer at---------------- Q -7 �.�-•---.�-I�- �2-!�X�..�t ------ � s=z�R-------------------------------------- has been installed in accordance with the provisions of TI i'�of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------ ............ . dated-............................................... THI. ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................................•-• -------------------------------- . Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - f� &. :1...�............0F...........t24- i ..'6-r................... FEE.7 Disposal Works To lion [rrmit r Permission is hereby granted............. ti:�................rur-C ---------------••--------------------------------------..................._ to Construct (>e� or Repair ( ) an Individual Sewage Disposal System �a at No..........i-.a--T----73-----------0-1-49----=5 �s ....l.�tCr= �fJ�- ..:�'� t ?...................................... Street � as shown on the application for Disposal Works Constructio rmit No. . .:_/./._ �. Dat ........ ....................... .. ................................... -- of Health ?72- DATE._...-•----- ----:.:��._....:... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Wit. 9 NdCe E4 i 1 L 3 5 No wa to t' ew hoot te�cedt 3S.z 7e.GG 3z.G pem 2;Kun P Li 9.p ( If cdp & t6p vi Satm -tot 70 IUD v ;e A R�r nedatrtif+-r. .. medium 40 1 wide — — — Y 4 N sae•4-26-88 _ t rt. t 3 3 100n y L ... i L w s r cr R M �c• l =f3 1 6 1y 6 pit ` ! I000 rg�.t U/I I atonet- .- �201 6f .tow �ea:%�K 4� '� 1127 "d No. bediiob�ir� zs rds 314ApoaciL' no i 37.4 3a®, ,3Coll cdti ut�,e'_itow ; 330. did '_ le acJwi c✓ted r 201; a j 201-- ' a .cat 714 7 if IA Lig { s. 37.5 noble No • Scale ldy 02601' - t , r ,Pq�tt R pNs Taff i �;.. - ✓ ; I L+ r io ch'un`'tey i ne. .1�' 1000 �,1,1 skd tch.'PtOA o� .cad ,t; vato"WA l , 'Aa i - tt t , 13eI�.,%gjj,Co�t 73 c.�. wK oK �c�d' oc'v�•�� ; �- � '--� -�-�-I '-t :-' P. t t j 31173 ti i. { { _I, ! - o EOWAR' Of J g . o KEG JO c I.NE Z, • � sTER.� .j,� 32490 Q • FSI-- � � ISTER�� Qom`` LOC&T10N ' SEWoC�E PERMIT UO. '=' /ILL •• � '— — — — — — as �0►1-i- - - - - -- IIJST LLERS oy1F, DDRESS BUILDER 5 ►.,y�ME "laDDSS Ale DGTE PERMIT 1S5UED `r '� — — -- 0 b.TE C04APL1&t dCE'I:SSUED : — — - --- — y9° y 41 p- 13ox j600 TOWN OF,BARNSTABLE LOCATION 2,2 , 00 IC) e�.=AtA t- /Qy SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 1( 0 (D(,OC) INSTALLER'S NAME & PHONE NO. Jc le f SEPTIC TANK CAPACITY 1 54 I �c► (C e d LEACHING FACILITY:(type) 1. �, �'✓o`"� (size) l� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER gg R� DATE PERMIT ISSUED: 5 3 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No QAD SA g® 3 i -71 7iZ _ q BARNSTABLE 7 3 TOE. LOCATION /� l SEWAGE # VILLAGE ��j �%Ili Ile_- ASSESSOR'S MAP & LOT INSTALLER'S NAME 6z PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) ; NO. OF BEDROOMS �J PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: c DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No t. 7 0 Commonwealth of Massachusetts �® W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 22 Old Salem Way, Osterville GSM Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8, 2015 required for every P page. Clity/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 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 bUb&—UAA---V April 8, 2015 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 C"J has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the FF report to the appropriate regional office of the DEP. The original should be sent to the system owner IX:1 and copies sent to the buyer, if applicable, and the approving authority. lz�l ,�y`. ""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 peTform in the-future under the same or different conditions of use. "Dii./pos.l t5ins•3/13 Title 5 Official Inspection Form: u Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 April 8 2015 required for every p page. City/Town 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 observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8 2015 required for every _ p , page. CityrFown 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8, 2015 required for every p page. Cityrrown 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 '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8, 2015 required for every p 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8, 2015 required for every _ P page. Cityrrown 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. ® ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , M 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 April 8, 2015 required for every P page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 years usage (gpd)): Yes Detail: 2013; 34,000 gallons and 2014; 40,000 gallons. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8 2015 required for every p page. Cityrrown 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: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is required for every Concord MA 01742 April 8, 2015 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: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line 10+: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank locate on site plan): Depth below grade: .5 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: 1500 Typical Sludge depth: 2" 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 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 April 8 2015 required for every p , page, Cityrrown 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 47" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 April 8, 2015 required for every p page. Citylrown 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: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8, 2015 required for every _ p page. Citylrown 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 effluent level with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solids carryover. box is 6 inches below grade. Like brand new Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 April 8 required for every p �il , 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: Unknown ❑ 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.): 6 foot leach pit with 2 feet of stone around. No ponding of effluent in pit. Pit is designed for 549 gallons per day. 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 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 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8 2015 required for every p page. City/Town 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: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8, 2015 required for every p page. Cityrrown 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 2_2 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8, 2015 required for every _p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18 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: Groundwater Contour Map ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 22 Old Salem Way, Osterville Property Address Nancy Gitto-Panagoites Trust Owner Owner's Name information is Concord MA 01742 Aril 8, 2015 required for every p page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E 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 - _ t . Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protecti , P VAIllam F.Weld Trudy-xxe n Argeo Paul Celluocl Ddvl B.3lruhs Lt.Cacwrnor Comminlo�sr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - 22 Old Salem Way CERTIFICATION Osterville Patricia• Rose Property Address: Address of Owner. Date of Inspeotiova �-��j �g �' (If different) Name of Inspector W.E. Robinson SR Company Name,Address and Telephone Number. 5 0 8) 7.7 5—8 7 7 6 W.E. Robinson Septic Service P.O. Box '1089 Centerville MA 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 sew disposal systems. The system: Passes" _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails ry Inspector's Signature: Date: . - The System Inspector shall submit a copy of this inspection report to the Approving Authority within.thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the . report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: X1bve of D: A] SES: found any information which indicates that the system violates any of the failure criteria as defined in 310 C.MRt15.303. 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): Describe basis of determination in all instances: If"not determined",explain why not) The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is nt. .The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved. 'by the Board of Health. (revised 11/03/95) 1 One Wint(w Street • Boston,r Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292-SSW . iAJ Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Addrem 22 Old Salem Way Osterville Owner. Patricia Rose Date of Inspection: B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C1 Elt EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 8) jysjMM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) ETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND A Uff 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 surface water supply. 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 50 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 ooliform 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 low than 5 ppm. 3) OTHER (revised 11/03/95) 2 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 Old Salem Way Osterville Owner. Patricia Rose Date of Inspection: ,7-t -,:k DI TEM FAILS: _ determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. the last year NOT due to clogged or obstructed i (s). Required pumping more than 4 tunes m y gged p pe Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EI LARGE S rSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or Aerator of any such system shall bring the system and facility into Bill compliance with the groundwater treatment program requirements 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 22 Old Salem Way Osterville Property Address` Patricia Rose Owner. Date of Inspection: '7 c7 t, Check if the following have been done: �umping information was requested of the owner,occupant,and Board of Health. �ne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �l/As built.plans have been obtained and examined. Note if they are not available with N/A. �/sie facility or dwelling was inspected for signs of sewage back-up. t system does not receive non-sanitary or industrial waste flow _, a site was inspected for signs of breakout. t/Ali system components,excluding the Soil Absorption System, have been located on the site. ZT111 septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tens,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. ✓eThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ►e facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 22 Old Salem Way Oster.ville Owner. Patricia Rose Date of Inspection:; ,c7 FLOW CONDITIONS RESIDENTIAL Design flow:3 3 a_fflllons Number of bedrooms: 3 Number of current residents: Garbage grinder(yes or no): Laundry connected to system(yes or no):� Seasonal use(yes ar no): qq I q Water meter readings,if available: wf S ! 017D Last date of occupancy: COMM IAL NDUSTRIAL: Type of hment: Design flow: „gallons/day Grease trap p nt: (yes or no)_ Industrial W Holding Tank present: (yes or no)_ Non-sanitary w i discharged to the Title 5 system: (yes or no)_ Water meter kgs,if available: Last date of OTHER( ;pancy: Last date ofcy: GENERAL INFORMATION PUMPING RECORDS and of information: System pumped as part of inspection: (yes or no)A,Q If yes,volume pumped: gallons Reason for pumping- TYPE O TLr1VI Septic terAl istn'bution box/soil absorption system Single cesspool Overflow cesspool Privy Shared rjstem(yes or no) (if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: p-'-R • 4- Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 22 Old Salem Way Osterville Property Addreac Patricia Rose Owner. Date of Inspection: rf f rl SEPTIC TANK (locate on site plan) Depth below grade:, Material of construction:✓concrete_metal_FRP—other(explain) Dimensions: - V Sludge th. " Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_�3 " I b , Distance from top of scum to top of outlet tee or baffle: ►6 Distance from bottom of scum to bottom of outlet tee or bane: 1 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of etc.) : y ,rje,`3 aREAs _ (locate on s plan) Depth below e: Material of co ruction:_concrete_metal_FRP_other(ezplain) Dimensions: Scum _ Distance top of scum to top of outlet tee or baffle: Distance from m of scum to bottom of outlet tee or baffle: Comments: (recommends on fbr pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) 22 Old Salem Way Osterville Property Address: Patricia Rose Owner. Date of Inspection: `?7_0 (9, TIG R HOLDING TANK:_ (bcate on plan.) Depth below Material of n:_concrete_metal_FRP—other(explain) - Dimension.: Capacity: ons Design flow: ona/day Alarm level: Comments: (condition of et tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: V_ (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.) LS L`a PUMP C _ (locate on site p ) Pumps in workin order:(yes or no) Comments: (note condition of p chamber,condition of pumps and appurtenances,etc.) VV— (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Old Salem Way O s t e r v i l l e Owner. Patricia Rose Date of Inspwdocc 7—jq—- 11 SOIL ABSORPTION SYSTEM(SAS): '+/ (locate on site plan,it possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type . leaching pits, number: leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments: (note condition hydraulic failure, level of of il,signs of h ulic�sp ponding,condition of vegetation,etcJ F.6 C l-Cc_ eiI I—. 1'' CESS _ (locate on ri - lan) Number and oo ration: Depth-top of lit to inlet invert Depth of solids la Depth of scum layer Dimensions of oeasp 1: Materials of constru on. Indication of ground ter: inflow(ees 1 must be pumped as part of inspection) Comments:(note tdition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY:_ (locate on site plan) Materials of oo a: Dimensions: Depth of solids: Comments:(note oo n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) 22 Old Salem Way Osterville Property Address: Patricia rose Owner. Date of Inspection: — SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 0. DEPTH TO GROUNDWATER Depth to groundwater feet method of determination or approximation: }24 (revised 11/03/95) 9 .* � .0 , ~° ~_ _ Fio-'°�l��-��-_ THE mommowvvsAcr* or mAseAonussTrs BOARD OF HEALTH ��11-----1.................................. �� ^� ��«��lir�otilluu ��u� Di-spaiiwul Works Toumitrurtiou» Vanoxt Application is hereby made for u Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ' ................... m" u/ __ Location- = uuz" _ ____- Installer Address TvneofBnilding Size Lot.---------'----Sg. feet Dwelling—No. c68�dr000�o----^�_----------_-- Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) P4Other fixtures .------------.------.-----__-----.-...------------------.--------'-'---'-- D ' Flow............................................gallons per person per day. Total daily flow............................................ . Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter--------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sg. ft. Seepage Pit IVo.-_----- Diameter.................... Depth below inlet.................... Total leaching area..................sq. b. Z Other Distribution box ( ) Dosing tank ( ) ~~ Percolation Test Results Performed bv.......................................................................... Date........................................ Test Pb No. l................oioutesperincb Depth of Test Pic.-.------- Depth to ground water........................ 44 Test Pit No. 2-------'.m6outesycr inch Depth of Test Pit-.-------- Depth to ground water--_---'-_.- '- -.-'--------_.---_-_'---_-__-------------'-'-_-'-'-_-'-_-------'_-'---'_'---- 0 Description of Soil........................................................................................................................................................................ --------------- ----------------------------'------------___'---'___''__------_-.---'--.--'----___-'------ .----_------.---------^-----------'-_-___--'_---_-'-----_'_-'-'---_----'_-_-'--'----' U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................................................................................................................................................................................................... Agreement: The d ' ed agrees to install the aforedescribed Individual S g Di 0 al System in accordance with ' the provisions of ZILE 5 of the State Sanitary Code d to place the system in operation until u Certificate c6 Compliance S ---------- -----_.-----'-^~1�' »�* ---- Application edBy-_-_---- -'��' ---------------'- -----. �.��'��.'��-- ~ "m" Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date Permit Datz . THE oommomxvEAcrn or MxsoAoHusErTs BOARD OF HEALTH , .........................................OF.............................................._..._��............. �� ~_ ��rtifur�utc 4x Tio4utpliatta CERTIFY, rh�~ System constructed ' ) or Repaired /k) has been installed in accordance with the provisions of TH-1Z bf he State Sanitary Code as described in the THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASAGUARANTEE THAT THE ' SYSTEM WILL FUNCTION SATISFACTORY. | DATE.---------------------------------------' Iooyectmc-----------------------------------------' ' ,; terra FRs..... ."..._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF......-................. Appliration for Uhipoii al Workii Tontra Lion "rranif Application is hereby made for a Permit to Construct ( ) or Repair { ) an Individual Sewage Disposal System at ......1./..,Q__...._.�� -�✓��/.................................. ...................... A 2`...---7-1............................................... Loatim-Addr s or Lot '_�o. ... ai��. �.1. �.._........................................................... ............•---•----•------•--...____________-- ------=---•-----•-----------.....-------._....-- near/ C� �j/ddress a % T.Cd.......... ..................... [...:.f�.��.i/`/_y................................................ Installer Address UType of Building Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms........ .................................Expansion Attic ( ) Garbage Grinder ( ) ` Other--Type e of Building ------------- P............... No. of persons............................ Showers Cafeteria a4 -----------------------------• --- ( ) — ( ) d 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—NTo. .................... Width........_........... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........:............ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pitt No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-_-________-_-•--____--. (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water______---__•____---_-__- a ------------••-•-•----------•••---••••••-•----•--•------•--•••-•---••-•--••-•--•-------••--•-•---••-......................................................... Descriptionof Soil ?---------------------------------•-----------------------------------------------------------------------------------•-----•---•-•---•-- W UNature of R-epairs or Alterations—Answer when applicable................................................................................................ ..---••-•-•-----------------•---------------•-----------•--••---•••••-•-••--•-•••-••._...•-•----•---•--------•--•.••----•----•-•-----•-••••--•-------••-••---------------•-•••---••••---...----••-•...-- Agreement: The undersigned agrees to install the aforedescribed Individual Se wag Disposal System in accordance with r'1T^ the provisions of TT �.a. 5 of the State Sanitary Code— The unde 'gn er a es not to place the system in operation until a Certificate of Compliance has bee s ed by th o r o Signed---• ........... ... .... ...... Date Application Approved By.................. .. -- " ---- Date Application Disapproved for the following reasons----------------•----....----•------------------------------•------------------------------------•----••-------- -----------•--•-••-----•--------------•-------•---•-------------------------- •--------------------•--------...-----••------••---•-••------- _ Date PermitNo. a. .. _..5--�------------------------ Issued........................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............:..........................OF..................................................................................... �rrfif irati� of Tompliaurr THIS IS D CERTIFY, That th In',+vlidual Sewage Disposal System constructed ( ) or Repaired } by-----•---•----..._... ""` -•_---•�...�:4�------------••-•-------------------------------------•------.._..............--------------...---.._..----•--------- /� .,-Innstall has been installed in accordance with the provisions of TIT"� 5 or The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... .�_._ ...: ...�....... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE " SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................................_------------------------ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Q Q - 19.7 /•••`•• •t c ��,........OF..........r3E -•�i,�. No... . ....... FEar....... ............ 14oposa orkii Tontr io Errant Permission is hereby granted. P t ....... �, r �. '-s �) ��- " -•--- .............----------------------------------••------_____________ to Construct ( ) or Repair (x) an Indilual Sewa Disposal �pstem r--- at No.............../,-e-, 7.�..-----...--•---... >_ / ` - =1"` WCc = i t."= ` Street Y as shown on the application for Disposal `'forks Construction Permit NoAL.5S.a' .. Dated.......................................... •---•-----•----------------•••-•---------- t--• --•-......-•-...------..._.._.....__.. of Health DATE......................... D FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ex , Je-4t pit #1)-6184 Xo•t 69 Irk-,de J 0-22-86 Wit. 7. .McKeah No wateA enco unt ezed 3 S.is 7 Z.G G 3;?. 2 nlin era �►1 r - I ? py ' . � p2' ' • .C'o-t 7 3 .26 AC. 3'2.47.r top -top � Otd �16 Z9.9 'al' Zy Z4• cte ' cctean Jot 70 jU .. R l v e ;t A R. RteaL/lK n±edvlr,� N � � 40 F wide d Sca f -`. J 11-30 1 �f t —34.I` - _ . 100 �+ Date LI-26-88 Q % - ! i Q37 04 pROPOsb I nn I i wArFR �lo•> �=IJ J-6 6 pV, i -- ! 19.9 19c= J0(0• ' LU I �,tonz t9• Q0low i qpd q No. bxon±i :, ' 3 zs' �Z i�poacLC no 37.4 3z•I i3• C4ii utte i.tow 330 qpd —Peaclun iatda 20J ay� ,r;.,a,�p•��. .C �} od. 74 caap`"''""" . 427 cpd ..a I gtt l Cap e £KQ�LVLePh�il1 L1q Pa�bo4, road 37 5 No ji& No Scale /lyanni4, ./tia, 02601.' i -.-- ..._�_ C•�G�F PC�M.tll 1�/C _Tr-f� A�.;.3--- e+' i ' _1_, �J 4-'_ 1000 :01 ��c Jc M N N;rl•. �,�•i tone L3.ci 1� Ia �- .. i J Sk8tch p&2 o? .Card; u O tewv,C�_, Md 902 Ch.aidd.CPhi 13bAtvotth. i . } , . , � , ' • � + lieu dot 73 as �lowl'i'o,ti .Ganef C'ol;i�% . .. �, { a-+ ptan 131373 Cb4wa-tt on.� C7/Le•OK an, acn±ed TJ t 11 ,+ I I t w j4 � o KE,;•i I Y • ��; �. J0± y ,NE s 32490 43 Q i L--t- 3s, AL