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Home My WebLink About0038 PARKER ROAD - Health 38 ParkerC"�Osterville) A= 117-108 a / 1 ,1 a i� 6 TOWN OF BARNSTABLE LOCATION 3,? SEWAGE # 93�� y� VILLAGE ASSESSOR'S MAP & LOT J(`7 /49 INSTALLER'S NAME & PHONE NO. JAh Au �fy Wov-7579�- SEPTIC TANK CAPACITY 0, LEACHING FACILITY:(type) GQ /leS S (size) /g X NO. OF BEDROOMS y PRIVATE WELL OR UBLIC WATE BUILDER OR WNE ;ee 14*IV) DATE PERMIT ISSUED: 7- /Z- g DATE COMPLIANCE ISSUED: q -3-b VARIANCE GRANTED: Yes No✓ v. 'l y � � � f �� s�/`� _ 'V f ®S �, ,� �^�/' � f � / sr l7 ! ,// /f� //7 ylr � � � � _•e _ i li �,,. - , C�pY L i,` r ../ %�a r/P� r� TOWN OF BARNSTABLE r i` LOCATION C��` -C' �''1�� SEWAGE #+T "II LAGE C �\mot �� ASSESSOR'S lb1~A1# &0� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by AePt g c �9 L AP 35 M 44' Commonwealth of Massachusetts �n Title 5 official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f; rya 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville V Ma 02655 4-23-19 ; F required for every page. City/Town State Zip Code Date of Inspection ij; 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. Inspector Information Sl# I a-'S-+- on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address VQ Sandwich Ma 02563 City/Town State Zip Code r�nv (508)477-0653 S113747 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); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ■❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 4-23-19 SON:m=Bre11 N+kh'.o,ou,emakolliceQDaMOexmvx4on.M.Fly '141o:301B.01.}506.489fi Bi'BB Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 I v—_ c Commonwealth of Massachusetts Title 5 Official Inspection Form �?l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 38 Parker Road u Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ,. . ❑■ I have not found any information which indicates that any of the failuie criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order.at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 r Commonwealth of Massachusetts �m Title 5 Official Inspection Form + 1.. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road �V Property Address Ronald Bardawil Owner Owners Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑. ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every 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 absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i! Commonwealth of Massachusetts �m Title 5 Official Inspection Form �? I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owners Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ❑ n Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ n The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El 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. i 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form i is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ El Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? Q ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ 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? ❑ a 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ Q Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �n IF Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN-flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440/GPD Description: ' Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes F] No Does residence have a water treatment unit? ❑ Yes Fol No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes [E No See below Water meter readings, if available (last 2 years usage(gpd)): Detail: 2017- 73,000gallons 2018- 51,000gallons Sump pump? ❑ Yes ❑■ No March Last date of occupancy: Date t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes X No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I, w�, 15 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: E Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 11411 Depth below grade: feet Material of construction: ❑ cast iron 0 40 PVC ❑other(explain): Town water Distance.from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 38 Parker Road u Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 4" Depth below grade: 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 1 Dimensions: 500gallons 911 Sludge depth: 2711 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 14" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons h Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No 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): 0'° Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): NA * 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: El leaching galleries number: (4) 4'x4° ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c� Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 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. The SAS was in working order at the time of inspection. No evidence of past back up was present. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 it Commonwealth of Massachusetts �m Title 5 Official Inspection Fora I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .� nsp '- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately LOCATION. SEWAGE'*, vur Ats t -C�3�t1 Ass�:ssor INSTALLERS NAME&PHONT NC, SErnp TANK CAPACITY LBACHIF1G1`ACILITY (type) fsize) 00.OPMEDROOMS__` BI7ILDER 0 Y)'1 NER PEFt2rtTfDATE —COMPLIANCE D1RI : S paaratiiai'Dtsuri,6e B+tiween tttc: .. Maxi*4di Ad usw0. Gtx u water TaHe-atsd Bottam.6f,L tueftutg Facility f Ptry ate�1'ater.5upptp Will and LeaCtung.Facility any wells ClUt" `: ass"j tq°,&,ividiin 200 feat Of=leacLing facHity); =�ir" 8 'of Wetland mi3 Lsaciiiitg-Facitity:'(1t airy wetlands exis f witlsin.>3t7a feet of.res,clvng e�i"t�ty) _�rxt , Furtished by " A III fit#" ° APB t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 required for every page.e. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ❑■ Surface water Check cellar Shallow wells No GW 5.7' below SAS Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 6-1-1993 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (t' 38 Parker Road Property Address Ronald Bardawil Owner Owner's Name information is Osterville Ma 02655 4-23-19 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 t5insp.doc-rev.7/26/201 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 COMMONWEALTH OF MASSACON�JNTAL AFFAIRS EXECUTIVE OFFICE OF ENVIR MENTAL PROTECTION DEPARTMENT OF ENVIRON w y ^ r a d A Q OW V 41 �� TITLE 5 —NOT FOR VOLUNTARY ASSESSMENTS OFFICIAL INSPECTION FORM SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION t Property Address 38 PARKER RD OSTERVILLE,MA 02655 Owner's Name: PHILLIP BATEMAN Owner's Address: 38 PARKER RD OSTER IILLE,MA 02655 Date of Inspection: 5/29/01 RECEIVED Name of Inspector: (please print) JOHN GRACI SEPTIC INSPECTIONS company Name: P.O. BOX 2119 TEATICKET,MA.02536 J U N 12001 Mailing Address: TOWN OF BARNSTABLE Telephone Number: 508-564-6813 FAX 508-564-7270 HEALTH DEPT. RTIFICATION STATEMENT dis osal system at this address and that the �iinfformatioanreported' below is CE certify that I have personally inspected the sewagep ection was performed base y roved system true,accurate and complete as of the time of the inspection.The insp The l stem: the roper function and maintenance of on site sewage).�sposaly systems. I am a DEP approved experience m p inspector pursuant to Section 15.340 of Title 5(310 CMR X Passes _ Conditionally Passes roving Authority _ Needs Further Evaluation by the Local App _ Fails 1� Date: 5/29/01 Inspector's Signature: Board of Health or DEP)within of this inspection report to the Approving Authority( d or greater,the The system inspectors submit a copy stem or has a design flow of 10,000 gp 30 days of completing this inspection. If the system is a shared sy submit the report to the appropriate regional office of the DEP.The original should e inspector and the system owner shall livable,and the approving authority. sent to the system owner and copies sent to the buyer, if applicable, Notes and Comments ECTION. RECOMMEND PUMPING TWO YEARS TO PROLONG THE THE SYSTEM PASSES TITLE V INP SYSTEM'S USEFULL LIFE. at time. ****This report only describes conditions a t the time of ht9peetion and under the conditions'ler��c�u�litions of use inspection does not address how the system will perform in the future under the same mspe , i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 PARKER RD OSTERVILLE,MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 38 PARKER RD OSTERVILLE, MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I 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 n/a "This system passes if the'well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: ' n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 38 PARKER RD OSTERVILLE, MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 D. System Failure Criteria applicable to all systems: You mast indicate"yes"or"no"to each of the following for all-inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to detennine 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a_tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well !I; 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 it should contact the appropriate regional office of the Department. n. Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 38 PARKER RD OSTERVILLE, MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks e X _ Has the system received normal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S Page 6 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 38 PARKER RD OSTERVILLE, MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents:3 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 7 YEARS Were sewage odors detected when arriving at the site(yes or no): NO i Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PARKER RD OSTERVILLE,MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 BUILDING SEWER(locate on site plan) Depth below grade: I I" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: 5" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a'Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5' 6" W 5' 8"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a , Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PARKER RD OSTERVILLE, MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PARKER RD OSTERVILLE, MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a 500 GALLON LEACHING leaching chambers, number: 4 CHAMBERS leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system n/a Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE FOUR CHAMBERS APPEAR TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY IN LEACH FIELD.NO MORE THEN 3 IN WATER IN CHAMBERS. SURROUNDED BY 3 FEET OF GRAVEL CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of 11 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PARKER RD OSTERVILLE, MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 6 c LIM o A o a , D � G C aN� A� �`� Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 PARKER RD OSTERVILLE, MA 02655 Owner: PHILLIP BATEMAN Date of Inspection: 5/29/01 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 11 +feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED FROM ENGINEERED PLANS ATELEVEN PLUS FEET Q .........P NO: l ✓ � ASSESSORS MA Fims.../�� , No.. . d J o il THE COMI�f'C 1 'f PPLTR—O ASSACHUSETTS APFQMD 8arnsteblo Carm=fta t BOAR® OF HEALTH w ...............OF.....I...... - ............................ Appl r Ou for Dispas al Mork,5 Tonstrnr#inn ranfit Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal System at: Q �j ( rG�. �✓ 1 A55;. Amp //7 pte—Z _ l4$ -— ............... ......................................................!:.......... -...---- ----------------------- —"'---..---..-.------------- .............................-- c i•Addr ss .........._.*........ .............. *.......... Lot No. Owner Address W Installer Address q UType of Building Y Size Lot_-_�_!_;97g-----.Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic WO) Garbage Grinder W21 pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) y--o-••-•-.••--------------------- Design Other 5�eS -•-----•-------g•--•-- P P P Y Y y .................gallons. * Septic Tank—Liquid capacity�fJ�. ..:.gallons Length.P.W.... Width_J`�!,6....._ Diameter-:.__ p . p Flow•- gallons per person per day. Total daily flow................. W x Disposal "�ene�i—No W>dth_./Q............. Total Length.............. Total leaching area_._. .._.__sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Other bution box Z Percolationr1Test Results Performed byl !!yn Q?�£-_---_aM.9"/� !�/ Date........................................ 0a Test Pit No. 1-----L.......minutes per inch Depth of Test Pit......I/---------- Depth to ground water.. fro Test Pit No. 2................minutes per inch Depth of Test Pit--------_........... Depth to ground water........................ ............................................................. ....................................................•....r---•--•........_........_...................................................................... O Description of Soil....... Z ........51l SDl�L U ----..._Z'."".._//.�. G;%4.�t�...�.��v�1..... �0-------•--•-----------------•••--•-•••-••-•---....-•--•-•-----....--•-•-••-- 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 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianc s b en issued by the board of health. Signed ... .. ....... ................... ... . Dace Application Approved By . ..;:k.. °"',�.1�-' �� ...-...-- ..-.-..---^'---'------.................... Dare Application Disapproved for the following reasons: ........................................ ............................................................................ ............ ...--....... .............................................................................. .. Permit No. ...................... Issued /�.. 1°'...��✓ . Dare THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) A-- nDA - r No................ . -. Flcs..........................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / ApplirFation for Biopoii al Works Tonitxnrtion ramit Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual Sewage Disposal System at: -ram, f.f'./.iY I:.�.F�` - f-r.��j I��fl . 10 y- .1 Location-Address or Lot No. ` ..... ......................fop '{ _ .. . ................................ ....................................••••-•...•-•---.............--••••......••.................... ....%.� Owner Address W Installer Address d Type of Building Size Lot___-- .......S feet Dwelling—No. of Bedrooms................_._._...............___.__.Expansion Attic (kh>) Garbage Grinder '4 Other—T e of Building No. of persons............................ Showers a YP g ---------------------------• P ( ) — Cafeteria ( ) Other fixtures ----------- --------------------------•--------- ---------- --- ------ W Design Flow............__.:,.z_......................gallons per person per day. Total daily flow____.______._.__._____:_____._ ..____.._.__gallons. W Septic Tank—Liquid capacity±'%'%..gallons Length.Z 2...._�.•.. Width_/,. %� .___ Diameter________________ Depth__`�.7 _.. Disposal T+-ei�i—No`.''? � y.�- . Width_./(> ----- g '•`=-----•--•• g ;------sq. ft. Total Len th..._-" Total leaching area y Seepage Pit No--------------------- Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( n Dosing tank '-' Percolation Test Results Performed by..........................r " ......................................` ^Y ��-- Date___.1. �7"(� W • ----....-•------•--...-----•. Test Pit No. 1.....�........minutes per inch Depth of Test Pit------ /............ Depth to ground water_. -_-__- fr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P ... -----•-------------------------------------------------••=-------------------------------------- --------- -------------------.._.. O Description of Soil----- '2_- at. ' C_. I/_;,; I -I,- ;, iL ............................ ......................................................................................................... ....................................................................-.................................................................................................................................. V 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliances b en issued by the board of health. Signed ........ .. '....----.� / I - .... r ----------------------------------------- ------- ----- J ', r Date _ Application Approved By F= - '" ,'- .:- >- ...." ....; e 1 C,r Application Disapproved for the following reasons: ..........................---------- ----------------- -- ------------------------------------------------------------------ ---------------------------------------------------- --------------- ------............................ Cf _ Dace f r' PermitNo. ;� ---------------..-...... ....<.::�.-...... Issued .............................................. ' ------- --------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................................. OF %��, -n./ C.C-- - --------------------------------------- GertYftra e of Qlampliance THIS IS TO,CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired b ! d: '_=I- ---.J- _--Y ---- - ------ - -- ------ -------------------------------------------------------------------------------------------------------------------- at fJ t= e" � � j'! ,1 .�' �; I�aller l" ---------- '--1.................+'=-y-,...r:..... ram:: -:...�y...--------�:......,------�- ':^....,.. .----'-......------........................--------------...................------..---------------`------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. q...:%........'."3_-.%. r.......- dated : :...`, "' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT`"BE;'CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION®SATISFACTORY. DATE ....................�---�-�----7 Inspector Inspector .............. --------------- :.......-------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No:... FEE...--.G;:1...=Z. Disposal Works Tonotr ion amit Permission is hereby granted_.__. _.___.__ ------ ..................................... .-- to Construct (�,• ) or.Repair ( '`) an Individual Sewage Disposal System at No . ram- r/ St r et - as shown on the application fo Dispf sal Works Construction Per No........____.____t__.:;tom`LDa/�k _.' ._'............ ...... / DATE---•--------------•-----...--i....-1-••�J/J-••-.f--��///----.._._._......... Board of Healt ; FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 9� 3.5 1 i Z 7.5- rl-T /Z Za�!o �/o / 8• o _Z ' \ Z ZOO S.F Wr Z/ 77/ / ' I _ -zo Of R OF �c JAMES C. sF MART N y MOORE � No.33253 acu IL 7 v o. 3 7�o Noce -t . _ /9v I 6k � t / l t_...e 4 GUAL7-,C Z2- . �� tvir �✓/z"ram_ (L�" TIG 7a ✓/1� . T�,✓� 18.3 17•7 f7- . 13,E ,� o