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HomeMy WebLinkAbout0036 RENOIR DRIVE - Health 36 Renoir Drive Osterville \ A= 146-123 Commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary-Assessments h� 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name information is Osterville, MA 0265,5 June 26 201`1. required for every page. City/Town State! Zip Code Date.of Inspection Inspection results musti be submitted ion this form. Inspection forms may not,-be,altered in.any way. Please see completeness checklist::at the:end of the form. Important:When filling out forms A. General anforrhatio:n. on the computer, use only the.tab 1. Ins ector' key to moveyour p.- , cursor-do not David D. Coughanowr use the return key. Name of Inspector Eco-Tech Environmental Company Name 43-Tdangle Circle , Company Address' y Sandwich MA D2563 Y f State Zip Code Cit /Town 508 364 0894. j 1328: TelepFione:Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this,address and that the information reported below is true, accurate and complete as of the time of ithe inspection. The inspection was performed based.on my training and experience in the,_proper function and.maintenance`of on-site sewage disposal systems. I am a DEP approved system inspector pursuant-to=Section 15;.340 of Title 5 (310 CMR 15.000).Th`e system: Passes ❑ Conditionally Passes El Fails ❑ Needs Further Evaluation by'the Local,Approving Authorify S June 26, 20,11 Inspectors Sipaturej Date The system inspector shall submit a copy ofthis`Inspecfion report to the Approving Authority(Board of Health or DEP,)within 3.0 days of completing this inspection: If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tb the buyer,.if applicable, and the approving authority., .,,.,This report only describes-conditions at the time of.inspection.And under-the conditions of;use at`ahat time.This inspection does-not a.d"dress h`gw the system will perform in the future under- Ithe:same or different conditions of use. ( n l.� a5ins-09l08 Tille,i.Offidal Inspection F.orin:Subsurface towage Df osol System•Pagel 0 17 k. Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface.Sewage Disposal System:Form-Not for Voluntary Assessments `~ 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name information is required for every Osterville MA. 02655 June 26,20:11 page., Cityrrown State Zip Code "Date of Inspection B. Certification (cont.) Inspection Summary::Check' A,B,C,D or E1 always complete all of'Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303'.or in 310 CMR 15.304 exist: Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass-this.Real Estate:Transfer Inspection;.if it does not trigger any of the failure criteria.listed`below. The.septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longeviity is made or. implied by a passing determination B) System Conditionally Passes_:: One or more system components-as.described in the"Conditional Pass"section need.to be replaced or repaired. The system; upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or no ) is structurally unsound, exhibits substantial infiltration orexfiltration 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 poss.inspection if,it`is structurally,sound, not leaking and if a Certificate-of Compliance.indicating that: he tank is.less than 20 years oId.'is available.� ❑ Y ❑ N ❑. ND (Explain below): t5ins•09/08 Tilte 5.0ffcial tnspeclion Form:_Subsurface ,ewageMisposal;Syslem-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Renoir Drive Property Address Richard and Noreen Galvin Owner owner's Name Information is required for every Osterville MA 02655 June 26, 2011 page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection If(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is.leveled or replaced Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due•to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: R ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if k 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 P t5ins-09108 Title 5 Off dal Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Tittle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 36 Renoir Drive Property Address _ Y Richard and Noreen Galvin Owne Owner's Name information is required for every Osterville MA, 02655 June 26, 2011, page. City/Town State Zip Code Date of Inspection. B. Certification (cont.) 2. System will fail unlessAhe Board of Health,(and Public'Wate.r 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. El The system has a septic tank and SAS and the:SAS is within a Zone 1 ofa public water , supply. The system has a septic tank and SAS and the SAS is within 50 feefof 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 coliform bacteria indicates absent and the presence:of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System.Failure Criteria Applicable,to All Systems:: You must.indicate "Yes" or"No"to each of the following for al{ inspections: Yes No Ej Z Backup of sewage into facility or system component due to overloaded or ,clogged SAS.orcesspool 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 bo.. bove outlet;invert due to an overloaded or clogged SAS,or cesspool ❑ Liquid depth in cesspool is less than 6"below invert.or.available volume is less than '/Z day flow t5 ns'-0W08 Title 5 official Inspection Form:Sub§urtec's Sewagebisposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ — Subsurface;Sewage Disposal System Form -Not for Voluntary Assessments w 36 Renoir Drive. Property Address Richard and Noreen Galvin; Owner Ow1.ner's Name information is. required for every Osterville MA: 02655 June 26 :2011' page; Cityr own State' Zip:Eode: Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in':the last year.NOT due to Clogged'or obstructed d pipe(s);;.N,umber of times pumped- . Any portion,of the°SAS; cesspool,:or.privy is below high groundwater elevation. Any portion:of cesspool or,privy s within 100;feeYof'a surface water supply:or tributary to a surface water supply. ,� 0 Any:portion of a cesspool'or privy is wit- a:Zohe 1 of a pu_biic well: Or 0 Any portion of a cesspool or privy is wrthin 50°feet of ra private water supp{y well, E1. R Any portion:of a cesspool orr privy is less than 1'00.'feet but greater thanr 50 feet from.a private water,supply well with-no acceptable water quality analysis. [This system passes if thewell wateranatysis; 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 by attached to this form.]" 0 The:system is!!a cesspool serving a facilitywith,-ardesign flow of 2000gpd- 10;000gpd The system fails, V.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 joAetermine what will,be. necessaryAo 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., Forlarge systems; you must indicate either''Yes"or"no'%to'each offihe following; in:addition to the questions,in Section;D. Yes No Q the system`is within 400 feet of'a;surface drinking-water supply the-system is!within;200 feet of..a tributary to a surface;:drink.ing,water supply El the system is locatetl In a;nitrogen sensitive area(Inte"rim Wellhead.Protetion Area:—IWPA}or a1, apped Zone I I of,a public water supplyweal 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 upgratle the system in accordance�with 3110,CMR 1.5.304. The system owner-8hould contact the appropriate regional office of the Department. t5ins;691os Title 5 Official Inspection Form;:Subsurface;'Sewage_D s'posal_SWiwi 'Page;S of,17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name information is required for every Osterville MA 02655 June 26 2011 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-09= Tate 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name information is required for every Osterville MA 02655 June 26,2011 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 75 gpd Detail 2009-2010 Sump pump? ❑ Yes ® No Last date of occupancy: ' current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•09= Tile 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 36 Renoir Drive Property Address Richard;and Noreen_ Galvin Owner, owners Name information i required-for every Osterville MA 02655 June 26,'2011 e page. Cityrrown State Zip Code. Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information. Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box,,soil absorption system ❑. Single cesspool ❑ Overflow cesspool. ❑ Privy Shared system('yes or no) (if yes, attach previous'inspection,records, if any) ❑ In.novative/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): t5ins•0jf08 Title 5 Official Inspection Fonn Subsurface Sewage'Disposal System Page 8 of 17 I , Commonwealth of'Ma tts ssachuse - Title 5 4ffcia.l Inspection Form Subsurface Sewage Disposal.System Form,--Not-for Voluntary Assessments. 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner ,Name, information is required for evey Osterville" MA 0265:5, June 26, 2.Q11 . page. Cityrrown State Zip,Code Date of Inspection. D. Sptem Information (cunt:) Approximate age of.all components, date installed (if known)and source of information- Age 27+ years. Certificate;pf:Gon pliance dated t 1/14/1983 (permit'.83-9"17): Were sewage odors detected Then arr vin at the site? Ye 9 g s No Building Sewer"(locate on site plani- Depth below;gratle feet Material of:construction ❑ cast iron 40 PVC Q other(explain;): Distance from private water supply wellor sueti'on.line: f e et Comments (on condition of joints;venting, evidence of leakage Sewer line appears-structurally.sound with,nd evidence of backup or`leaka a into dwelling: Septic Tank(locate on site plan): I, 2 Depth,below grade: feet Material of construction: concrete; Q metal Q'fiberglass, E] polyethylene. Q oth;er(explain) If tank;-is metal listage: years Is age':canfirmed by-a.Certificate of Compliance'(attach a copy.of certificate) Q Yes Q No Dimensions: 8.5,ft x 6:.t x 6'ft.(1000'gal) - Sludge depth: 4 in t5ns•'09/08. Title 5 OKctal Inspection Form:Subsurlace;'S6v ge Disposal System Page;9,of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system form-Not for Voluntary Assessments 36.Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name inform ed far every information is Osterviile MA 02655 June 26 2011 requir page. Citylrown State Zip code Date of Inspection D. System Information (cunt:) Septic Tank-(cont.) Distance from top of sludge to bottom of outlettee or baffle 30 in Scum thickness 1 in Distance fromp,to of scum to top of.outlet tee or...baffle 9 in Distance,from bottom of scum to bottom of outlet tee or baffle 14.in How were dimensions determined? Design Plan Comments(on pumping recommendations, inlet and outlet tee or baffle condition,,structural integrity, liquid levels as related.to outlet invert,,evidence.of leakage,etc.): Pumping is not fequired at this time but maintenance pumping is recommended within and every two years. Tank appears:structurally sound and functioning:as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan)' Depth below grade: feet Material of construction: El concrete ❑ metal ❑fiberglass ❑polyethylene. ❑ other(explain): Dimensions: Scum thickness Distance from 1op 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 15ins•69108 Title 5 Official Inspection Form:-Subsurface Sewage Disposal:System-.Page 10 of 17 m ILN Commonwealth of Massachusetts a _ - Title 5 Official Inspe' cti0,n Form _ a Subsurface Sewage Disposal System Form =;Not for Voluntary.Assessments. 36.Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name information is required.for.every Osterville MA 02655 June 26; 201.1 page. Cityrrown We Zip Code Date of lnspection D. System Information (cunt:) Comments (on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity; liquid levels as related t6ciutlet invert, evidence of leakage, etcs)` Tight or;Holding`Tank(tank must be pumped at time_of inspectioO(locate on site plan) Depth below grade:; Material of construction: ❑ concrete ❑ metal ❑ tilergla'ss ❑ polyethylene Elother(explain): Dimensions Capacity:, , gallons Design Flow: gallons per day Alarm present: ❑ Yes. ❑ Na Alarm level- Alarm in working,;order,;. ❑ Yes ❑` No Date of last pumping: bate Comments(condition of:alarm,and flootswitches, etc;): "Attach copy of curren(pumping contract(required).As oopy attached? ❑ 'Yes ❑ ;No l5ins:e 09108 Title 5 Official Inspection Form'Subsudace_Sewage&isposal"System�Page t'1 of`17 Commonwealth of Massachusetts Title 5 Official Inspection Farm a Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name information is required for every Cisterville MA 02655 June 26;2011 page. CityfTown State .Zip Code Date.of Inspection D. System Information (coat) Distribution.Box(if present must be opened)(10 ate on site plan): Depth of liquid level above outlet invert Comments.(note ifbox is level and distribution to,outlets equal, any evidence of solids carryover, any evidence.of.leakage into or out of bo), etc.): D-box is under paved driveway and not accessible for nspection..System has instead been evaluated on the condition of the leaching:pit-see page 13. 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.): Soil Absorption System:(SAS)(locate on site:plan, excavation not required): If SAS not located, explain why: 15ins-os/08 Title 5 Official Inspection Form;Subsurface,Sewage Disposal System t Page 12 of 17 Commonwea th of Massachusetts -__ Title 5 Officia.1 Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary.Assessments. 36 Renoir Drive Property Address Richard and, Noreen-Galvin Owner Owner's.Naine information is required-forever y Osteryille; MA 02655 June 26,2011: page. Cityr'rown State., Zip Code' Date:of Inspection D. System Information (cont) Type: leaching pits number ❑ Teaching chambers number:; leaching,,galleries; number: leaching,,trenches number,.length: El leaching fields number,dimensions; El overflow-cesspool ntarnber:: ❑_ innovative/alternative system Type/name_of tec.hnology: C'omments'(note condition of'soil, signs of hydraulic�failure,level of pondingi damp soil; condition of vegetation, etc:):: Leach;ing pii-was,uncovered and found;to be d', with no stainin observed'into riser.. Cesspools(cesspool'must be pmped;as p'?O,Of insp'ection)`(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 groundwa,tef inflow ❑ 'Yes;. ❑ No (Sins•99/98 74109(k.. Inspection Form;Subsbrface;Sewago:Disposal Systerri P.age.13 of fZ ,' .. may. Commonwealth of Massachusetts uiTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name Information is required for every Osterville MA 02655 June 26, 2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): !Sins'09708 Title 5 Official Inspection Form:Subsurface Sawage Disposal System•Page 14 of 17 Commonwealth of IVlassachusetts _ _ = Title 5 Officia:l Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 36.Renoir"Drive Property Address< Richard and Noreen Galvin Owner Owner's Name information is required for every, Osterville MA 02655 June 26, 261'1 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage,Disposal System:,Provide a-View of the sewage disposal system,including ties to at least two permanent reference:landmarks or benchmarks: Locate all wells within 1 00 feet. Locate where public watersupply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached'separately L Flu j �' x SPh j , i5ins•69l08 Tille,5 Offidal lnspection.Form:Subsurface.:Sewage bisposalSystem Page 15 6f,77 Commonwealth of Massachusetts Title 5 Official Inspection Form — " — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's Name information is required forevery Osterville MA 02655 June 26, 2011 page. Cityrrown -State Zip Code Date.6f Inspection D. System Information (cant.,) Site Exam: Check.Slope Surface water' ❑ Check cellar ❑ Shallow wells feeett Estimated depth to high groundwater 2 ft. 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: 6/2104 Date. El Observed site (abutting propertylobservation hole within 150 feet of SAS) Checked with local:Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation), Accessed USGS database-explain: -.Barnstable GIS Department records You must describe how you established the high ground water elevation`. Septic design plan shows bottom of leaching pit to be 6 feet:above the bottom of witnessed test pit in which no groundwater was observed:.Town of Barnstable GIS Department records,indicate that the property is over 20 feet above groundwater table, Before filing this Inspection Report; please see Report Completeness Checklist on next page. t5ins-0908 Title S:Official Inspection.Form:Subsurface Sewage Disposal System•Page 16:or 17 i Commonwealth of Mas,sac.husett& M-ATitle 5 Official Inspection Form Subsurface:Sewage Disposal System Form -Not for Voluntary Assessments 36 Renoir Drive Property Address Richard and Noreen Galvin Owner Owner's-Name: information is required for every Osterville MA' 02655 June 25, 2011` page. Cityrl own, 'State Zip Code. bate.of Inspection E. Re;port Completeness Checklist Inspection Sdri mary_•A, B; Q, D, orE.checked ® .Inspection Summary D (System Failure Criteria.Applicable#o AII'Systems)completed System,:Information—Estimated depth to high groundwater Z ;Sketch.of Sewage Disposal system,either-drawn on page I 5,or attached b separate file r t5ins:•.1�/08 Title 6 Offi Inspection Form:Subsurface Sewage Disposal Syslem•.Page 17 of 17 LOCATION , SEWAGE PERMIT NO. VILLAGE I N S T LL 'S NA �:a ADDRESS ® UILDER OR OWNER DATE PERMIT ISSUE- DATE COMPLIANCE ISSUED ' !.. �� � � 9 -�� � � . . a1 �'i _ _ J NoD..'-.Y17 Fiza...... ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1c� 6' OF.......................................................................................... 3C� Appliration for Eliopoottl Works Tonotrnrtion Prrmit App3lication is hereby made for a Permit to Construct, or Repair ( ) an Individual Sewage Disposal Systemat.....1 ....... ............... ..... .... .................... ................ .. Locatio Address or N . l..�. Owner i Address .. �- ,r4j �� .. �r�.._.:.� j >~ �� ....... .............. ��� ------•-••-------•--•----•---•----------. Installer Address Type of Building Size Lot-.. `f�..�..4--O..Sq. feet U Dwelling—No. of Bedrooms.............. ---------- Expansion Attic "�l�age Grindertj- a p,, Other—Type of Building ................�..._.... No, of persons............................ Showe ( ) — Cafeteria ( ) dOther firs .........................................................••-••-•-•-•-•-•--.....:---------•--•---•---•-•-•-----.......--••--............_......._-•---- W Design Flow.............)'_5.......................gallons per person per day. Total daily flow.............1,..7..(-..................gallons. WSeptic Tank—Liquid capacity d.9 ..gallons Length................ Width................ Diameter-_______--_-_- Depth................ x Disposal Trench—No. .................... Width.................... Length.................... Total leaching area....................sq. ft. Seepage Pit.No..................... Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. z Other Distribution box (el Dosing tank ( ) .— 9 `-, ----.......••-•-- Date----... ..- V Percolation Test Results Performed by...............................r.� Z.T Test Pit No. 1...L4 .4 Sminutes per inch Depth of Test Pit........1,e....Depth to ground water......., ,SG , fs, Test Pit No. 2._.....4-6—......mmutes per inch Depth of Test Pit.................... Depth to ground water........................ •----------------------------•-•--------...y�. . ,/......L..... . O Description of Soil....................................................... ... :.... . ....--•--------••�_._� v`-- ..-5-��---.....-------- .------...-•-----------••--------------•---------••------••-•-•............-••••-. -------•-----------------------------------•----•--••-•-•----------••••••-•••---------- -••••-••••-••••--------••-•-•--•----•-------------------•-•-•--••-•••-••-------•-•-----•--•--•-....._•---...--- VNature of Repairs or Alterations—Answer when applicable..........:..................................................................................... ----------- -------•--------•-.....-•----••-----•--•----.....-----------------------•---.------ •........ --••-•---------------------- .-........ ---................. -......... ................. ............ Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by the board of Aealth. . .............. .................. ........................ . Application Approved. B �Ey.�......: D PP PP yI. .............................. ,r -- •--.Date Application Disapprovellowing reasons:............................•---...-•-------.•............--•----------------------------- •---------......... ---•-----••---------•---......•-••.............................................................•-•-------.................•----•-•................--•-•••-----•---•---•--............ ...--•-------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD. OF HEALTH ..........P44-VY4`(r.......O F......................................................................................... Appliration for Did mial Workii C ontitrurtton rumit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ,�= D .......................L 4..................(2.........---•---......�Y�a�n A...........----......---�--�� ................................ . ......... Locatio Address or Owner 1 Address Installer Address UType of Building Size Lot_ _.�..1.G__O..Sq. feet Dwelling—No. of Bedrooms--------------- -- --------------------Expansion Attic A% Garbage GrinderZy aOther—Type of Building ________________�.._..... No. of persons............................-Showers ( ) — Cafeteria ( ) a Other fi q;res --• ---------------------------- - W Design Flow.............)...?.......................gallons per person per day. Total daily flow............1.1..0..................gallons. WSeptic Tank—Liquid capacity.t4_v..Q._gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet_.._____.___._______ Total leaching area..................sq. ft. Z Other Distribution box (� Dosing tank / - / p Percolation Test Results Performed by............................r..` ................. Date....... a Test Pit No. I---L -_S.�minutes per inch Depth of Test Pit........./_ �_ Depth to ground water......./�,/a�,,�.�,•- �14 Test Pit No. 2........4L--.minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----•------•-----•-----•--•--•------------- .................. ODescription of Soil.....................................................................•---•-•••------------------- ................� .Z� "�' y _ f.E, ......._ _ a... ............ -------------------------------------•----------------._.......------------.....------------------------------------------------------------------.........------....----------------------------...... 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu by the board of lth. . Application Approved By........ ..... .. ..............A �G /..--•---- --------.................... Date Application Disapprove or a following reasons:............................................................................................................... -_-•---•--•---•-----------------------•------•••---•••••-•--•------------•-••---•---•------..........-•••---•---•...................__.......___...-----•---•-•------....-----------------•-•--•----•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA T ........."'!""' ,! -............OF............//'-! ....... . ..................................... T Trr#ifirtt#r of Toutplittnre THIS IS TO CERTIFY, That the Ipclvidual Sew:3gt Disposal System constructed (Kor Repaired ( ) by------------------------------------ .�....... ..... .��//-....-:iv_!.f__....-o_�l_.................................................................................................... at-------•-•-•....................................• .. ... 2- Q. Instal . (^ �._ .. 15 has been installed in accordance with the provisions of T T 5 f `e State Sanitary Code a in the application for Disposal Works Construction Permit No._ .^ � - --------------•--- dated---........... ---------..._..-----------•-----.. THE ISSUA)RCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL F CTION SATISFACTORY. G DATE... ....... Inspector = ................ ",/ ;� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �?".� ......: ..........OF............. .. /................................ v N ......... FEE.. ............... Bispwial 10orkii 1QTom r ' n rrm Permission i hereby granted..................... ....4,A..z.f.............. - •-/I ................................................. to Construct (L4 or Repair ( ) an Individual Sewage Disposal Syst * (1 - at No--------------•-•- "'�` ---- 7dt Q-! ,l /.. -.......-"7- F1... - . 0 T reet as shown on the application for Disposal Works Construction P • ' . ............ Dated.......................................... ................ --•...................•-- ............................................................ DATE.: Board of Health /D, Z/�Y.-__.---------•._______- FORM 1255 A. M. SULKIN, INC., BOSTON .10TF /F E!TNER Tt,I�'3c�T/:C TA.V rC p,4 !N T y %E JO P7: J�1/A/. _ p4-� TN A:•! /2."9EL 0 iv �. - e - Y .� .ylwG .fE . MORE Bar '9 UGNT. TG 4RA0Z COJVCJWA AV 9�PV t,+E.4VY CAST /RO YE G` P/PR "lI/V. P1TCI�1 /Y G 4 S%�F L L :3J - r_' EL ,�SS ' COY�RS `�"pfi4 FT `� /F/1V L7R/VEii/A.y ., i fiA 6 •a C r 3/v pim rr S�Pri� T.�Iw/� /sT. • : • aaX 49 ,_ _ _� • r, •a. DEpTtI • . ►' • 3V.43rrED STdN c o s . • • • • •• /• q . s 1BSx ? s 4?� � • • . . . • o • .s •• j -7� • • • e • • s• . Poi PRECAST SEEP,4GE'`'- ±° jlli/YP/eT E'LE/�I�]r/OAI� (/T Cp4P�!`CI r j� 48 roAL/�DAr �� .• • • . • • , s �' • �.• P/7 0.4 U/V. ris ivctr d�r.C': 3�E_ o oy►'rtiT SPTIG Ti� iPac �" w {T `" Fr. y.�i4M C{sFa raeuL..�r ^�) AN ITli!' /AIST lIb4�tlt'/OJV ' .SEGTIdJif. 004 GROvNO I�GgTEI� Ti1QLE -~ IN+Cr aE.�t�►t :-_F7C SE'h/Aa� EJ_/.SPAT ; . t�1�'f'�!/Y�► __.7�181lLATtQ/I1� DFS/6X CRITEI�i« - - sewer = : t'-o' oipfEivsiOIMAWow NNIlSER of OEG� &V's slow 8 S/ON GARaA6.Ep/SP0514L&vir- NVNF Solt. LQG 740TAt.E-171, NTEo FLOrV 3 3 y G�►t �ItW SO/L TEST A/ TO/4 TES77*2 �'LIIL TEST /irUMB a 0.40-l,BAGI/jf#W P/TS CLEY. 7a 3/DE L1'ACH/NO /•T. ZY/ Y3 . .9a rrOM OER PlT15� �^ 7 RESULTS-iVITiVESSEO BY J J-JAWSI 5�38���- PERCOLI►TIO/v RATS / ;1 2 ... ZOTi1t J.Z4CN//YG'AR&A fT_ �'tlht�INtK RESER%ELE.�1G'Iv1N6,4RE/'► Z b�' ', R�•tCOL.�TioN'CA AF AZ / r - Tb � /983 OF1✓{s {. ( /5.a m5�►�h LOT z-a �C—NDiIz-�2cv� o� RQBE r o2. LB I vf D S:-7 4E-: 1?V/ L�.-,E ' o p RSE N109 DREDGE cN&IIV Ee71jYG.CIO /•YC. i -IST ty�d 90 OST \��c, 71Z,'"A//V .ST- , !YYA.vNc'S. ,ugsJ , { �Cgkp ti� �Fp` ��U LET lV0 G/;OG/Nv rY.4TL'/! FNCOCJNTE'��G GL/EIVT 'DR Q GROU.VO -H.�TER '4T lrZ_ai! /Z �5.7n� SHEET f G Aso 2� 0 0� Z'13 S� 6. ; -� Ln r ell 10, ry �L) of CERTIFIED PLOT PLAN OF YH ,4 H M fsT \ r07;20 l» ,3V4Z5, dGt�7' 7�A oM5 Cor� o� AL ROB cn S )e--' � At GE I N is � MORSE ,- No'10951 A9�FG/STEP G/STE��O�� A A�I`� �5 1A E '_.8oi M iA:�.1.J_� �FSS�ONALEa� SCALES / ��' DATE LOREDGE ENGINEERING Ca /N �i�Ech/oRcrz F CLIENT.., I 'CERTIFY THAT THE PROPOSED, AINEGISTER REGISTERED J08 N0. .BUIL.DING 'SHOWN ON THIS PLAN , CIVIL LAND CONFORMS' -TO THE ZONING rLAWS p EIVOINEER AS_L'E MA -QR ` 7I2 MAIN STREET H µ .�` �,_� % 1� H Y A N N I S, MASS : ° Mf �� ��� � _ SHEE'TOF DA E REG: LAND SURVEYOR. 1� (ry �y �S 31 Fxs.............................. THE COMMONWEALTH OF MASSAC,HUSETTS 1 3 BOARD OF /HEALTH 1 ('. .....OF....................... ........................................... I Appliratiun for Ui_qpuuttl Works Tuntrurtiun ramit Application is hereby made for P mit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: j.�.n........... ....•--�........... �........ ... Location ddress A or Lot No. ��` ........0 .._ ...-•--•-•..... .4....... ........ ,- ..... caner `` Adtrress W ,{ �.�1.5.�..�F..S.. ....................... ............................ Installer Address d Type of Building Size Lot...J_Yt�d.c?.....Sq. feet U Dwelling—No. of Bedrooms........................................Expansion Attic ( Garbage Grinder (A� Other—T e of Building ............. No. of persons........_................. Showers — Cafeteria a' Other fixtures ..._ Design Flow........................ }}-...._..gallons per person per day. Total daily flow............-r�.(�................gallons. � Septic Tank—Liquid capacity......Ytallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width_.__._......__._. Total Length Total leaching area._._________.___._..s ft. p ... g ,------------------- g q Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching ar sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by......................:....•• ......... - ---571,1 ._--- Date--------- --_- --------. t_._. Test Pit No. 1..4 ie5l.minutes per inch Depth of Test Pit- ....}}. ......._. D th to ground water......................... Test Pit No. 2--- I�.�-minutes per inch Depth of Test Pit.................... Depth to ground water........................ o ••••----------•-----------•---ca•-....._ ........................... :. Descriptionof Soil----------------------•----•----.......------••-:'.. ._--••••... .--- •------ ....__.... U --------------------•----------------••----------•---------....... - _ .... w / 2 � 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 Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been •ssue y the boar f'heal WApplication Approved BY ............_•----••. -----•-----......-•-..._--•-......._•••••-••-• -•--�®- -•-• Date Application Disapproved for..Me f o110 'ng reasons:---•---•............................•--•----•-----•-•--•--•---•----------------..............-•--.....•••---•--- �. ..........................................................................•------•--------•-•------•-•----•---••-•------.........._.................._.._._._......._•--•-•---•----•--------------•-•--- Date PermitNo......................................................... Issued....................................................... Date I No.Y.A-- 4 E:jc F .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ....OF....................... ............................... for Dhipasal Work.5 Tomitrurtion Vamit Application is hereby made for aLrPermit to Construct or Repair an Individual Sewage Disposal System at: (, .2 . .................... .......... ............................................................................ ....................... ...............................D..5).. ..... .... Location,Vddress or Lot No............a ...... ........................ C 014 P -%Owner 7 Adffress ­ ............................................ ...... .................................................. ............................. Installer Address Type of Building Size Lot. . .. ........ .Sq. feet U Garbage Grinder (^-)S Dwelling—No. of Bedrooms............. ......."",--,"Expansion Attic (A-0 Other—Type of Building ---------------_------_--- No. of persons............................ Showers Cafeteria A4 Other fixtures .- --e� �_.4,r--------------------------------------*........*--------------------------------------*-----------------..... ------------- ------ WDesign Flow......................... ........ gallons per person per day. Total daily flow........... ................g-,dlons. 04 Septic Tank—Liquid capacity--- _..__..gallons Length................ Width.___.........._. Diameter-_-_--__--___._. Depth................ Disposal Trench—No. .................... Width_............_.._... Total Length_._......_.._._..... Total leaching area....................sq. f t. Seepage Pit No...................... Diameter......__._.......... Depth below inlet....._..........._.. Total leachinj areaf.................sq. f t. Other Distribution box Dosing tank ( ) W'FL=A, _ Percolation Test Results Performed by------------------------ Date......... ........... ...... Test Pit No I minutes per inch Depth of Test Pit.... to ground water........................ Depth to ground water........................ Test Pit No. 2...,J:_44!�nniinutes per inch Depth of Test Pit..._................ ........................................... ------------------------------------------------------- 0 ......................0...................... ----------- Ay........ ....................................... �4 Description of Soil-----.............. .....................i!�.......7.. .. U ......................................................................./........ .........................ji:-�------- ------------------------------------ ............................................................................................................. ...........................I.................................................... U Nature of Repairs or Alterations—Answer when applicable.__............................................................................................. .................................................................I...................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned furtly agrees not to place the system in operation until a Certificate of Compliance has been issue the boar f heal0(/ Sie ............... ............ . . .................... ... ........... ............5- ApplicationApproved By................. ........t............................................................ ....................................... Date r So S..... Application Disapproved for th ollo ing reasons:............................................................................................................. ........................................................................................................I............................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS -1 BOARD OF HEALTH ............( ...Lf Ite...........OF......................(5 .................................. (Infifiratr of Toutphatta THIS IS TO CERTIFY, Th or Repaired ,.a,t-the Individual Se-Arage * osal System constructed,�k by---------------------------------------------------------- . .......................................................................................................... I taller at............................ .................................................................. ----------------------- ................... . . ............. E has been installed in accordance with rtiie provisions of TITLE 5 State Sanitary Code a -c e in the application for Disposal Works Construction Permit No.... ............ dated_...:...... ......... .......................... THE ISSUAN CE F THIS CERTIFICATE SHALL NOT BE CONSTRYP AS A GUARANTEE THAT THE SYSTEM W I Lj ZFF I ION SATISFACTORY. ................................................... DATE... Inspector--- .. ....................... ............................................... 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL HEAL* POO—_OF................ . .. ...... ... ............................................ .............. ............... .... No............. FEE...T.............. EbVoiial Works Tom&udliwn it '___ A.�0 iolto Permission is hereby granted---------...........!- / t... ..... .................................................................... to Construct X or Rep q!.c,�,—) an Individual Sewage Disposal System atNo................ ......2..fj-------------/140;--- -----------V-/S..............0.. ... ................................................ Sfredt as shown on the application for Disposal Works Construction Permit No:.... ... ..... Dated.......................................... ..................... .......I.......................................................... Board of Health DATE....................................... . ................................. FORM 1255 A. M. SULKIN, INC.. BOSTON t - • r V P / LvTz � r ` \L LEGEND CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION Ox0 8 41 ,. EXISTING CONTOUR ——— 0 - - - ��ZN�i�si`�t Lu / Z. / FINISHED SPOT ELEVATION '• �FINISHED CONTOUR 0 SFRUCE ' 6 ELD(2EC IN APPROVED BOARD OF HEALTH N. � I �, y DATE AGENT °�;{„ su ;� SCALE � " ., G�.�c✓B Rr�`2 tLDREDGE ENGINEERING CO /N CLIENT I CERTIFY THAT THE PROPOSED r'REGISTERE REGISTERED JOB NO, 8 �z n BUILDING SHOWN ON THIS PLAN CIVIL LAND �.. �. �,.� CONFORMS TO THE ZONING - LAWS ENGINEER j RVEYOR. DR.BY OF ARNSTABLE I MASS. _--71 2 M A I N STREET ' R_- T3. Z CH. Bl( � H Y A N N 13, MA SS. / --- A ==SUR_-j ._ SHEET.._. OF DA E�'� REO. LAND VEYOR y l DOMMO co r (�a n � .� O �b a,�: .g;♦ tom' l.�tir �.J� 1 r Cr, Ca �� • fT1 ,^ ` �. •. - �f, � W ` � �1. F P.I`IY�:, .M��1`�' �•r� :k. � � .;r� `F" ���°' � .:.r'(' ®._ iy,. 5,•?1,7,,Yr .�rt r',g � u�t `N`� pC . �, �- a d n ,ar" � y'���,`-•.fir ,�. . , � G ` tj "7 + �� p•� fir + ,,h D : ® y:. qb 41 Tj fj Zj th 7 F •ri i � •�1 n `) o ►�. m SUM d ;Abo �� ,.. � � . • . . . e� . • �. � a ` ° +� ♦ t✓j �" /1 0 .0 y y� t .� •. � b •. 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