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HomeMy WebLinkAbout0233 OLDHAM ROAD - Health 233 OLDHAM R AD, OSTERVILLE A= 45016, 1 i o ; 1 Oct 18 2618 11:57 HP Fax page 1 Commonwealth of Massachusetts Title 5 Official Inspection Form . �R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments __0 233 Oldham Road Property Address Sandra Largay Owner Owner's Name/ +::3 information is every Osterville!F required for eve MA 02655 10-6-18 gym.* page, City/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. Imp000nc utfoans When filling out l A. Inspector Information 6k on the computer, use only the tab James D.Sears = JAMES key to move your Name of Inspector rp SEARS cursor-do not Capewide Enterises %*'. use the return key. Company Name •.•RT I F 153 Commercial Street '��i�F S INS t, WQ Company Address rN MONO Mashpee MA 02649 City/Town State 508-477-8877 zip Code S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); i have personally inspected the sewage disposal system at the property address ' listed above; the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-9-18 Pp,,taors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15insp.doc•rev.712&20t8 Tltle 5 Official Inspection Form:Subsurface sewage oisposai system•page 1 of�8 Oct 18 2018 11:57 HP Fax page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owners Name information is required for every Osterville MA 02655 10-6-18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and S. 1) 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. Anyfailure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and two chamber's. 1 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or`not determined"(Y,N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official InspecEon Forn:Subsurface Sewage oisposal System•Page 2 at 18 Oct 18 2018 11:57 HP Fax page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments iv�I 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information tan is Osteryllle required for every MA 02655 10-6-18 page, cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s), The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3 Further u r Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Pape 3 of 18 l Oct 18 2018 11:57 HP Fax page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information is required for every Osterville MA 02655 10-6-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorptions stem SAS and the SAS is within Y (SAS) 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well, ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.712612018 Tlde 5 official Inspedon Farm:Subsurface Sewage Disposal System•Page 4 al 18 Oct 18 2018 11:57 HP Fax page 5 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form .I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .vP 233 Oldham Road Property Address Sandra Largay Owner Owner's Name Information is required for every Osterville MA 02655 10-6-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than %,day flow J_EAe#1Ni' ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fai s. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributaryto 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 15lnsp.doc•rev.7/26/2018 Tilte 5 Ofrdal Inspection Form,Subsurface Sewage Disposal system•Page 5 of 18 it Oct 18 2018 11:58 HP Fax page 6 Commonwealth of Massachusetts Title 5 Official Inspection F Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wv - 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information Is required for every Osteryille MA 02655 10-6-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for aR inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)] t5insp.doc•rev.7116M18 Title 5 DfAaal Inspection Form:Subsurface sewage Disposal system•Page 6 of 1s Oct 18 2018 11:58 HP Fax page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information is required for every Osterville MA 02655 10-6-18 page. CItyrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15,203(for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal. Tank D Box and two chamber's. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2016-199,000Gal g ( y g (gpd))' 2017-139,00OGal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date 5nsp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f Oct 18 2018 11:59 HP Fax page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owner's flame information is required for every Osterville MA 02655 10-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2, CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc,): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc rev.7/26/2018 Tille 5 Official Inspedl on Form:Subsurface Sewage Disposal System-Page 8 of i8 Oft 18 2018 11:59 HP Fax page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments X 233 Oldham Road Property Address Sandra Largay Owner Owners Name information is required for every Osterville MA 02655 10-6-18 fie. city/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the IJA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 1981 10-2018 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18" feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH-40. t5insp.doc•rev.7/26/2018 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Oct 18 2018 11:59 HP Fax page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owners Name information is required for every Osterville MA 02655 10-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: t3 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: 1000 Gal. Precast H-10 Sludge depth; 2" Distance from top of sludge to bottom of outlet tee or baffle 28' Scum thickness V. Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt Jape Sludge Judge 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 at working level.Tank and covers at 8" below grade. In and outlet tees. No sign of leakage or over loading. 15insp.doc-rev.7/26 )18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 19 I Oct 18 2018 12:00 HP Fax page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owners Name — information Is required for every OSterville MA 02655 10-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.712612018 Title 5 Official InspecEon Forth:subsurface sewage Disposal System-Page 11 of 16 Oct 18 2018 12:00 HP Fax page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm •Not for Voluntary Assessments . 233 Oldham Road Property Address Sandra Largay Owner Owners Name information is required for every Osterville MA 02655 10-6-18 page. Cityrrown state Zip Code Date of Inspection D. System Information (cons.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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 16"x16"-20" below grade w/one line out. Box is new 10-2018 w/cover at 6". t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 18 f Oct 18 2018 12:00 HP Fax page 13 c Commonwealth of Massachusetts Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owners Name information is Osterville MA 02655 10-6-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovativetalternative system Type/name of technology: t5insp.doc-rev.7128018 Tltte 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 18 Oet 18 2018 12:01 HP Fax page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - g p Y Y • 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information is Osterville MA 02655 10-6-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two flows. Chambers at 2'below grade.Wet bottom w/no sign of over loading or solid carry over. 12. Cesspools (cesspool must be pumped as part of inspection)'(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•rev.7126=18 Tide 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 14 of 18 Oct 18 Z018 12:01 HP Fax page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information is required for every Osterville MA 02655 10-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.726/2010 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Oct 18 2018 12:01 HP Fax page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information Is required for every Osterville MA 02655 10-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (conk) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately of 0 3 13-1 141z 36 r t5insp.doc•rev.712612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I Oct 18 2018 12:01 HP Fax page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ( Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information is required for every Osterville MA 02655 10-6-18 page, CitylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells MO 10' Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: i Auger T.H. 10' no G.W.. Bottom of chamber's of TV below grade. Bottom of chamber's at 6'6" above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev,712612018 Tile 5 official Inspector Form:Subsurface Sewage Disposal System-Page 17 of 18 Oct 18 �018 12:02 HP Fax page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form kr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 233 Oldham Road Property Address Sandra Largay Owner Owner's Name information is Osterville MA 02655 10-6-18 required for every page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2,3,or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included PQ 3`-6 �D r/a CNAmA Nv G,w i t5insp.doc•rev.11 WO 18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 1 B LOCATIO '7,3 SEWAGE PERMIT NO. 0- 67 _ VILLAGE INSTA LLER'S NAME & ADDRESS 0 U I L 0 E R OR. OWNER DA T E P ERMIT ISSU E D - - 1?-3 A - DATE COMPLIANCE ISSUED t 6� `�c ' y � � II li No. 20t 1 703 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftPlitation for -Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repaij Upgrade( ) Abandon( ) []Complete System Xindividual Components Location Address or Lot No. JL33 OLD(ft M Q b ®Tt- Owner's Name,Address,and Tel.No. SAtJDP_4 LAAC-ih-1 Assessor's Map/Parcel 14,5 ®/ dL 3? C?�`-W4 PO VI-e-LZ. Installer's Name,Address,and Tel.No. 57pQ-(477-SE 77 Designer's Name,Address,and Tel.No. Cps eiDEl�3©* adrk� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1i I gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) :r�-TAU_ jV C-Uj 6nY w rTk b t � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si Date 10 _q_�®l�' Application Approved by Date 4.0 Application Disapproved by Date for the following reasons Permit No G - 30 ? Date Issued " �� WIVW No. 20 i�,"�o Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISIO - TOWN OF BARNSTABLE, MASSACHUSETTS Yes N P applitatlDitjorlksposal �6pstrm Construction Permit A PP lication for a Permit to Construct air' * Upgrade k ( ) Re P ( ) Abandon( ) ❑Complete System �Individual Components Location Address or Lot No. a33 t:7UIMM Qa ©Srw Owner's Name,Address,and Tel.No. SAND� ��{RC14r� Assessor's Map/Parcel 14 5�f�ly "ot33 �c-oN+4+�c D vr�c Installer's Name,Address,and Tel.No. 508-({T7•.8&-77 Designer's Name,Address,and Tel.No. '`; c�r�co Czv-1�2s�►sT I R�3o,�r� N�� Type'of Building: Dwelling No.of Bedrooms Lot Size sq ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures /y Design Flow(min.required) N ✓t gpd Design flow provided gpd i Plan Date Number of sheets Revision ate Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answer when applicable) =5_-Uk NEEC,y D-&A- 6j rrt-4 P1 56 i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the.Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. s Signed Date '( �"c�•Q Application Approved byn,,, ,� Date Application Disapproved by Date f ,for the following reasons Permit No. 2 01 try,- 3 6 ? Date Issued /� � t/ -,I°/ 0 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS d Certificate of Compliance THIS IS TO C��E�pRTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( X) Upgraded( ) Abandoned( )by t�.ltC�Ft,�J! C NTCl2l��C.CSFC / at._0-7}"; -OL DRAM. I} 65—r, has been constructed in accordance- with the provisions of Title 5 and the for Disposal System Construction Permit No. e I?-SO T dated /d` �� 2 e /g�. Installer( 40,1-Wt NE 6AJ7Wd_P.C(S&-1C Designer NIA #bedrooms � I,/� Approved design flow ti Z/4- gpd The issuance of this permit shall/not be construed as a guarantee that the system willffERibii-as ddesigned. Date f Inspector --------------- ------------------ No. / O rf d Fee 7 1;w THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoBal *pstrm Construction Permit Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( ) System located at �--' L„1)1{AA4k and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permsr"'AL,- Date u J l / Approvedby � � �� � jam•- v - Michael DeDeckNTLANTIC ENVIRONMENTAL j y P.O.BOX 2384 0/ MASBPEE;MA 02649 Attn: Commonwealth of Massachusetts Date: 02/10/96 Town of Barnstable Board of Health 367 Main Street Hyannis MA 02601 4 From : Mr Michael DeDecko F Ric f Po Box 2384 FB Mashpee MA 02649 °.: 1996 C. 4 Dear Board of Health Official; I certify that I have personnally inspected the sewage disposal system at the following address : 233 Oldham Road, Osterville Ma. The information reported is true, accurate and complete as of the time of the inspection. I have not found any information which indicates that the system fails to adequately protect the public health or the Environment. If you have any questions regarding this inspection,please contact me at this number: (508)477-14-20. Thank you. Si ere , Michael DeDec o 4 phone 508 477-1420 . e J i tl In 1 _ _ x 1-7 � � _ `a _ �'- ,�� �, � a.. , `tom' �! �• �? .,.� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : Owner: -5:N O 1}'IUIQ jL i Date of inspection: Iq SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. QI Iwo O �"WM,S10,vS 16T, R z a5: az '01,4 Flo„ �,�►wb�L �3 yZ.(, 0 t DEPTH TO GROUNDWATER: Depth to groundwater: .) geet Meth d oqf deter i lion or apRroK five: .: l-J. ��c�.t�...l.tV.✓�5.�.��R�?(.�i�....lt:�-�°��...1�..�.,. ��!.z...... ! ..ivert�e,..s,.rs....Sl�a► ..£sT� .t�� ..I.' e. > 1�1:��11dt Q. !t?J°t. ..i�f !ol . .1 T`. ..1`t., .......�Jb...q�,(�1 ...!fl�7.�p,;..V.U� •• "I y 42 4 i Commonwealth of Massachusetts Executive of Environmental Affairs DEP Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM` ' PART A CERTIFICATION E Property Address: 00 h m '996 Address of Owner: i4C6jZl "t--NV-1r�vw����,� (if different) y ,V �/�,�,��s t�J� •� F Date of Inspection: Name of Inspector: Company Name, Address and Telephone number: 1411�C- ✓�rcoNwl 1 r�\ `�o•36 23Q•��,�QYhQ��� dye ,c�Z,��� CERTIFICATION STATEMENT $ I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system J Passes --•- Conditionally Passes -- Needs further evaluation by.the local Approving Authority Fails Inspector 's Signatur ; t 41 _'/ . Date: C? Cq j �-0 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 shell submit the report to the appropriate regional office or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer,if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �'�D Ol a h ft, Owners: T K 0 Rgot4Ti ` Date of Inspection: l INSPECTION SUMMARY: Check A,B, C,or D A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY NALLY PASSES: ---- One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. n Indicate yes,no, or not determinate(Y,N,or ND). Describe basis of determination in all instances. If "not determinated",explain why not. ---- The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- 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 ayear 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : o'% ®\&VG , Q a Owner: -T viNNmcvATi Date of Inspection: a�S lg(. C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health ,safety and the environ- ment. 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 of water ---• Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a 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 analy- sis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: --• I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. ---- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: d3 b o k&)gv Y1 Owner: UN kWeA-j j Date of Inspection: a1G 1� D)SYS T E M FAI LS (continued) -- 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 over- loaded 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. -- 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1nVVN\ Owner: Date of Inspection: E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : -•- 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 r operator of an such system shall bring the system and facility into full compli- ance The owner o op y y g y y P ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please,consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ok,hftvv\, Owner: kW\ ' Date of Inspection: Check if the following have been done -yPumping information was requested of the owner , occupant and Board of Health. :X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X- As built plans have been obtained and examined. Note if they are not available with N/A. - The facility or dwelling was inspected for signs of sewage back-up. -_ The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods X- The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. 4�' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: NNWNl6rZr�T j Date of Inspection: (� l�►ro RESIDENTIAL: Design flow: 3 3 O gallons Number of bedrooms : G3 Number of current residents: o Garbage grinder (yes or no): ►J 6 Laundry connected to system(yes or no): yRS Seasonal use(yes or no): (� Water meter readings, if available: CO 30 36 D Last date of occupancy: COMM ERCIAUINDUSTRIAL: - Type of establishment: Design flow: gallons/day Grease trap present: (yes or no) Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no) Water meter readings,if available Last date of occupancy Other: (Describe) ....... . .................. ........ ......... .............. ................. Last date of occupancy: s, GENERAL INFORMATION gM�PING RECORDS and source of information: System pumped as part of inspection(yes or no):.....1 D......... if yes, volume pomped: .................... gallons Reason for pumping ............................ ... ... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: a33 6idV\ m R� , Owner: Date of inspection: 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) ... Other (explain)....................:...................................................................... APPROXI ME AGE of all components,date installed(if known)and so rce of information �...I�a .aF. .1.�� �i�. �.1.►� s. .s�`d,... �t �.. ... :. ...L�.�ti.c .... ,,......... Sewage odors detected when arriving at the site: (yes or no).....ss SEPTIC TANK: . (locate on site plan) Depth below grade: ...C5�� Material of construction: .... concrete ......... metal ........ FRP........ other (explain) ................................................................................................................................................ Dimensions: Sludge depth:...3:.`....... Distance from top of sludge to bottom of outlet tee or baffle:.....a�. L................... Scum thickness :....o" Distance from top of scum to top of outlet tee or baffle: .........10......................... Distance from bottom of scum to bottom of outlet tee or baffle:...0 .................. Comments (recommendation for pumping ,condition of inlet and outlet tees or baffles, depth of liquid level in re at' n to outlet invert, stLuctural integrity, evidence of leakage, etc. ............. : ..0. ,.XA. l.,t�.Q.Q o. ..ka. �.��+ -. . . .. ..sa !�� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: aa3 &Acnrwy�,Q-J, Owner: Date of inspection: 0A(U GREASE TRAP : .....OP..... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... ........................................................................ Dimensions:............................... Scum thickness:....................... Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: Recommendation for pumping condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.).............. ............................................................. TIGHT OR HOLDING TANKS:...!!.Q.... (locate on site plan) Depth below grade................ Material of construction:........concrete........metal.........FR P..........other(explain).......... ..................................................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee,condition of alarm and float switches,etc.) , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Address: a-6-b OI cI VN , Owner: k'N1pl�ji Date of inspection: DISTRIBUTION BOX:..Lie (locate on site plan) Depth of liquid level above outlet invert:.J"s.__L2..2,qjo& . Comment: (note if level and distribution equal evidence of solids carryover,evidenc of leak9ge into or OLA of ox, , n... .,...5, 5 . 1�d1.... v4...,,. .. :�.tG� .c: C:.... .................... .......................................................................:........................................................................ PUMP CHAMBER:...►,y.O.... (locate on the site) Pumps in working order: [yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.).................... ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):... . .5........ locate on site plan,if possible; excavatidn not required,but may be approximated by non- intrusive R intrusive methods) if not determined to be present, explain: .........................................................................................................................................:...... Type: leaching pits, number: .................. leaching chambers,number:l: ..... leaching galleries, number:........... leaching trenches,number ,length:..................... leaching fields, number,dimensions:................... overflow cesspool, number:.......... Comments: (note condition of soil,sign of hydraulic failure,levgg I of ondi g, co diti of vegetatio et .).. corn . ... t. r. s. ....h ,. .. ... .A!�.►�.. �U 1c:,�:��. ��a�i.... . . ......... .... . ... . ... .1�:� . . cry nur►r ,�, gram ,�o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property ad r ss: �33��h(FYI(` vA t i%'1'0j1([(JL- Owner: Date of inspection: all CESSPOOLS:.....�NQ.. (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. ................................................................................................. Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) ................................................................................................................................................ ................................................................................................................................................ PRIVY: ... d...... (locate on the site) Material of construction: .................................... Dimensions: ........... imensions: ........... . Depth of solids: ..... .......... Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.). ...........................,..................................................................................................................... f N .! _.6 ..L r rr ' . Fps.. ._°_/...._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® C F HEALTH ,01 b l A).......OF............. ... � . - ----...•... Appliration for Diipnsaal Works.TonStrnrttnn Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ,. System at ..r Lo n- ddress or Lot Ijho. � ZV �fy,4 OwnerA r... ................................... W t�-ltLN Installer � Address Type of Building Size Lot... ---_.j .��� .Sq. feet U a Dwelling—No. of Bedrooms.....: ...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons......._—,........... Showers Cafeteria ( ) Otherfixtures. ------------------------------------------------------------------------------------------ WDesign 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..__.`Q_..._. Depth below inlet.................... Total leaching area........... ..sq. ft. Z Other Distribution box ( ) Dosing tatik `-' Percolation Test Results Performed by....,4(?...e.r ........ Date. aTest Pit No. 1.......-�-�-s-minutes per inch Depth of Test Pit.................... Depth to ground water_-___-__-____-___..-_,__- fi, Test Pit No. 2_...._..r�_._..nutes per inch Depth of Test Pit____________________ Depth to ground water........................ 1 :. le cr><pti of Soil r.c�.,.. ............ �-� = = `" U ....=- ..................... ° E ---------------------------------------------------------.......--- ---------.......... x -----------------------------------------------------------------------------------------------------------------------------------------------------...............=....................=............. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIlLU. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een 's ed by b 11 of health. ate Application Approved By............. = ��p ��/ � /1-------------- Date Application Disapproved for the following reasons:............................................................................................................... .............................•---•.........----•....-----------•-----........-•--•--•------•---...._.......----------------------------•--------•---------------•..........-----•-•- -----••------- Date PermitNo......................................................... Issued....................................................... Date yr FE$..�..... ..�............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD . F .HEAL t-I , t -...... �11,r✓ -.....oF........... Appliration for Disposal Works Towitrnrtion Prrutit Application is hereby made for a Permit to Co struct ( ) or Repair ( ) an Individual Sewage Disposal System at ................... ........... . ......... ........ .. ..... ' LooaT nn Idd ess or Lot o. A Owner ress W 1........ r r�....-- . :.. ............. ... '4 Installer Address ++�� Type of Building '�1 Size ...7 _F�_0_-_� .Sq. feet ►-, Dwelling—No. of Bedrooms....... ................................Expansion Attic ( ) Garbage Grinder ( ) a' Other—T a ype of Buildin g ____________________________ No. of persons.........��--. _:_____...... Showers (,2L— Cafeteria ( ) � Other fixtures .----•------------------------•. . ----------=.---••------•----•--•••••••-•--..................... W Design Flow............................................gallons per person per day. Total daily flow__-__-_-•_-_ ..............................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width....... Total Length.................... Total leaching area----------------....sq. ft. . Seepage Pit No........./--------- Diameter._....._.O-_-_-_. Depth below inlet...::............... Total leaching area. ...__:_. __sq. ft. Z Other Distribution box ( ) Dosing k 0-4 Per-formed Test Results Performed by._-. -....��:--_I,-.._...._. !�/ Date..................... . ...........I._...._ Test Pit No. I.........C4i_4iinutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 44 Test Pit No. 2...............7rr mutes per inch Depth of Test Pit.................... Depth to ground water........................ De�crlptinn of Soil C� ---� 3. ..............cc� _Z.------ ... ......�-� -----�--Z...... - C U --------G '.... -----------•-------------------------•-----•----•---•-•---- 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 S of the State Sanitary Code— The undersi ed further agrees not to place the ystem in operation until a Certificate of Compliance hasyens d by b of health.Seed- ----------••--•.........-••••-•---------•--•--••-..._------ z4 A lication A roved Bd �(L � '�-------------• .... � ev PP PP Y -� -------- -------------•--....----............... Date Application Disapproved for the following reasons------------- .................................... .............................................................. .........................................................................................................---•----------------------------•--------------------•---•--•-------••--•-• •---------....... Date Permit No......................................................... Issued...------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F" HE err ....OF..................................................................................... enrrtif it atr of (�tirnt�rli�anre Tyls IS TO, CERTIF ,'That he Individual Sewage Disposal System constructed (5�r Repaired ( ) by...... • --- an�� - t at....-'� _. C`...... •-- ------- .................................................... has been installed in accordance with the provisions of T� / j yT� 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.....3. .................... ...................................... Inspector. ............................................... THE COMMONWEALTH OF MASSACHUSETTS �-...... BOARD F HEALT rs•% ....OF.......... ... ........................... .................... No...:.................... - FEE........................ Rsvos a Works Tnnif nrt' n unfit Permission is ereby granted -••--•••-•-•V................................................................ .... to Construct r Repair ( ' )ren-In ividual Sewage Disposal System atNo.. L-- --..: .......................... Street as shown on the application for Disposal Works Construction/P-er i No..................... Da L ._.__........:_•_--_-•--__...___ Board of Hea h DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS r 1Y 1 t� .� ;� � e` � ' � 4 E� ,� THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) MB E DA , TA Y -tt Jf'�.. f j } i r 2ti (7� 284 t.F: eEAc.N, re fo— 6Z I �. 5! a U r n Gig 53 f /' �% A iv i a/r v F { /ROE RT !1 p t NP.I LEGEND E�IYIt�Q SPOT ELEVATION_ OxO ` E IPOTiNOr CONTOUR = — CERTIFIED PLOT P!AN P8A9i3HED SPOT ELEVATION p O Lvr G 'RiWt��OEC CONTOUR p � OVED 60ARD OF HEALTH IN ®AYE � 1 � 40L9,m� ,. AGENT_ . SCALE: � - 3 c) ` DATE • ' I U/ GE ENifiol 'RING Co CLIENT_ Etl18TERE REGISTERED I CERTIFY THAT THE PROPO$Ep CIVIL LAND JOB N0. �' BUILDING SHOWN ON THIS PlA1�' URVEYOR DR.BY ' R ,' ,` : CONFORMS TO THE ZONING L � OF BARNST BL , MASK 712 MAIN ST. CH. BY: k ; HYANNIS MASS. SHEET—L OF OA E R pO FT. MIN. No E' : /P @ SL'PT/C TANI►r IS= MORF . : S Thfi414/ /2'./w ®'S D6QI i�l� gPdf. A" 24. ' /D '9::M/N. : _ �NCI�I. D/A/�06'�"6tR 4"PVC /m/PLr . C� 4VdS4r. TO .40Aefs' e•4N 'LcXTRA /YZAVy A37/RON'COVER SWALG Be` l/SleD lF'./N t,: CO:VCRE7E /�9/N. P/Ttff . COVERS FT�B OR/YEH/Ay .PtR M/m 40TADE „ .y ra LIQUJ'D LEVEL CLEAN SANO -b /ROA/ PIPE ..GAL:.' �- --:---- -;---- %L� . ,`• r M/A/. P/7CN SEP77c TANK - ;4•` %4•PER FT. L LEAC1411VG .. . • ' SECTF GROUND WA? /ON O ER.7A BL£, Sew AGE.D/S OSAL SYSTEM TA6L14Ar1ON v C.EEACH.IWO F/ELO �� ' SCALP - Y4.7 a. /i-O.f D//��NS/O/V 8 ,�FT 3 FT. f T. $O/L TEST: SOIL. 400 OF �d 3/p" SOIL TEST #/ SOIL.TEST*2 1N.4SNEDSTOA(.E DATE OF JOIL TEST s/ V �J -6GEV T o i FSO,' ELF. h RESULTS•/ IZAIESSED Ar �' .P '3'�w"► i,5 , , p Z ' Lr PERCOLAT/QN RATE /�% /'� s M/M�JNCI! ��� SANO PERCOLAT/ON RAT�f }0�2.; �� �M!%V�/NLH „1- f, • DES/GN CR/TERlA, Q-f. A"' M S A I•/.' /2., ru,vr NUMaER Of BEDI`DONS 3 •r t^!.A / Fi n!c s �. / ASNED'JTU NS /i nF r- GARdtABE 4:16 h 4171 ESTIMATEP FLOr✓ 3 GALwAy �/ y °p.LEACHING =AREA O f' SECT/ON �C "` ���,� tescRVE "A�tEAcL as + a^ " ; Y SCALE : f f -D - 'Iv®GROuM®:kVVA ENCOUNT Wro �✓A70R AT ELE.Y lt' /NVrE/4T E . /N✓ERT AT'EU/L.D/aG '7,U FT. ✓1 L� C r. 9 , TAN6f FT. - G OT S�/I..McJST BE /ZE,/`1U✓EA O(JTL.I'? $EPT/G:T.�9Nd( l3.EL=0N/ CL.Ay LitEQ /►r'f% R�.��A � wiTk C,L �/ /NLe'r owso w ur/o/v our .' eE�L.DR�OG� �f�NEE�R/N6',fQ, :S'A.wo. To A s DUT.t�tT e�lss�rwm�/� r A Nia� MASS r'Wj IEFw PrE _ - a