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HomeMy WebLinkAbout0448 STARBOARD LANE - Health J 448 STARBOARD`LANE, OSTERVILLE Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Star board Lane r4^M Property Address f Michael &Trudy Sullivan_ Owner Owner's Name - information is Osterville MA 02655 December 20, 2012 required for ----- ----- -- - every page. CityfTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any . way. Please see completeness checklist at the end of the form. Important: A General•Information .____._ When filling out forms on the computer,use 1. Inspector. only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address --- ------ ------ -- 4 Marstons Mills MA 02648 - reran Citylrown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification ? ' I certify that I have personally ins sewage disposal system at this add s and that tf e information reported below is true, accurate and complete as of the time"of the inspection. The inspeion was performed based on my training and experience in the proper function and ma ntenance= on site sewage disposal systems. I am a DEP approved system inspector pursuant to ection IV40 of{ Title 5(310 CMR 15.000). The system: r a ; ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaitjation by the Local Approving Authority \•., I ,. _ December 20, 2012 Job# 12-278 Ins ector's Signature Date + The system,inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sentto the buyer, if applicable, and the approving authority. " ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. l5ins•11/10 Tille 5 Official I pe on Form:Subsurface Sewage Disposal System•Page 1 of 17 r i r Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane — Property Address Michael &Trudy Sullivan Owner Owner's Name " information is Osterville MA 02655 December 20, 2012 required for __..---—-- ---Code D— ate of In every page. City/Town State Zip spection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15 303 or in 340 CMR 15.304 exist.An� failure criteria not evaluated are indicated below. Comments: Tank was scheduled for pumping following inspection, leaching trenches showed no evidence of saturation. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or:'not determined" (Y, N,,ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank.(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced vvit a cOmplying septic tank as approved by the Board of Health. *A metal septic tank will pass.inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank-is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael &Trudy Sullivan Owner Owner's Name information is required for Osterville MA 02655 December 20, 2012 - --- -- every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to,broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y -❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health:, ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR • 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment`. ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Tale 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael &Trudy Sullivan Owner Owner's Name information is required for Osterville MA 02655 December 20, 2012 ----- ---._-...---------- ----- — --- every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the'SAS'is within a Zone 1.of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less.than 1.100 feet but 50 feet or more from a private water supply well**. - Method used to determine distance: . _ **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No , ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ❑. ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•11/10• Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 1 Commonwealth of Massachusetts" Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael &Trudy Sullivan Owner Owner's Name information is Osterville MA 02655 December 20, 2012 required for --- -- -- ---- every page. City/Town State Zip Code° Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. E] 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.] ❑ ® The system is a cesspool'serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. ° E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or".no" to each of the following, in addition to the questions in Section D. Yes No V ❑ ❑ 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 Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection ED Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in.Section D.above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department. 15ins•11110 - Title 5 Official Inspection form.Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 448 Starboard Lane _--_=- Property Address ------------------•------ Michael &Trudy Sullivan -- Owner Owner's Name information is CIS erville MA 02655 _ December 20, 2012 required for -- Zi— - every page. Cityrrown State ' p Code e 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? El ® 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'. ® 0 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: ® F❑ 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 El approximation of distance is unacceptable) [310 CMR.15.302(5)) D. System Information Residential Flow Conditions: _ 4 Number of bedrooms (design): 4-------7- Number of bedrooms (actual): 440 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): ISins•11110 • Tltle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael & Trudy Sullivan Owner Owner's Name information is Osterville MA 02655 December 20, 2012 required for ---- --..—— ----- every page. City/Town State Zip Code Date of Inspection D. System Information Description: • I ....a_._............ ...._._ _.:_ ._.p_:___. .. 2 Number of current residents: 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 Seasonal use? ❑ Yes ® No N/A Irrigation Water meter readings, if available (last 2 years usage (gpd))F' system. Detail: z Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): ---- ---- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: -- t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 7 of 17 I • Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael &Trudy Sullivan _ ......... -- .._...-- Owner Owner's Name ------------ ----------------=------ information is required for Osterville MA 02655 December 20, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Daie Other(describe below): General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: ga - gallons , How was quantity pumped determined? Reason for pumping: - --- - ------ -- -- Type of System: ® Septic tank, distribution box, soil absorption system ` ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or,no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection. of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. , ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael & Trudy Sullivan Owner Owner's Name information is required for Osterville MA 02655 December 20, 2012 -- ---------------- -._...--------- every page. City/Town State Zip Code., Date of Inspection D. System Information (cont.)` Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain):Q — Distance from private water supply well or suction line:' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank locate on site plan): Depth below grade: 1 - feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: ' $.5' long x 5.2'wide- 1000 gal. Sludge depth: 4 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a V/. 448 Starboard Lane Property Address Michael & Trudy Sullivan Owner Owner's Name information is Osterville _MA 02655 December 20, 2012 required for — --- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 26 3 Scum thickness 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 101, 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.): Liquid level was found at bottom of outlet invert and tees were intact. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or�baffle Distance from bottom of scum to bottom of outlet tee or'baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 __ I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael &Trudy Sullivan Owner Owner's Name information is Cisterville MA 02655 December 20, 2012 required for -- ---------- -- every page. City/Town State Zip Date of Inspection Code D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: -- --- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: ---------- Alarm in working order: ❑ Yes ❑ No Date of.last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract (required). Is copy attached.? ❑ Yes ❑ No t5ins•11110 Title 5 Official inspection Form Subsurface Sewage Disposal system•Page 11 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address ---------`--------- - ---._--------------- Michael & Trudy Sullivan _—.— Owner Owner's Name information is Osterville _MA 02655 — December 20, 2012 required for ---------- -----._ . every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): o„ 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.): Trace of solids carryover,no high stains. _. 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: t5ins•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael &Trudy Sullivan__ Owner Owner's Name ' information is osterville MA 02655 December 20, 2012 required for ----- -- --- — every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number:_ Two 30' trenches t r ❑ leaching trenches number, length. ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: --------- -- — Comments (note condition Iof soil, signs of hydraulic,failure, level of ponding, damp soil, condition of vegetation, etc.): Lateral lines were video inspected with no signs of surcharge found. Cesspools (cesspo.ol must be pumped as part of inspection) (locate on site plan): i Number and configuration Y Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layef --- ,'Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No • t5ins•11/10., Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., 448 Starboard Lane Property Address Michael &Trudy Sullivan _- — -- -----..-----------------.--------_-----._--. Owner Owner's Name information is Osterville MA 02655 December 20, 2012 required for ---- — - -.._.-_..__ --- - ---- every page. Cityrrown State Zip Code Date of In D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — --------- - ----- Dimensions. --- — Depth of solids -- -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 448 Starboard Lane , Property Address Michael & Trudy Sullivan Owner Owner's Name , information is Osterville MA 02655 December 20, 2012 required for _-- _ _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below:. . ® hand-sketch in the area below ❑ drawing attached separately - - Back . :+..;l,. `. . . . ./..1./. ... .-. Yard 13 '42 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 448 Starboard Lane Property Address Michael & Trudy Sullivan_ Owner Owner's Name information is required for Osterville MA 02655 December 20, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground fe water: 1 +/e 4 et Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record 'If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain established the `You must describe how you e high g ground water elevation: Elevation of surface water at rear of property is lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•11110 rille5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 448 Starboard Lane Property Address Michael &Trudy Sullivan _ Owner Owner's Name information is required for Osterville 02655 December 20, 2012 --- -------------- _MA__.____-- -- --- every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria.Applicable to All Systems) completed' ® System Information— Estimated depth to high groundwater. ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 A 1 CO%I',IONN E.Ai TH OF MASSaCHliSETTS 'o EXECUTIVE OFFICE OF ENVIRONMENT.kL AFFAIRS - DEPARTMENT OF ENVIRONNTAL PROTECTION ME ONE nINTER STREET. BOSTON NLk 0210E (617) 292.5500 TRUDY COXE Secretar% ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Comrnissio;er ,M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A LAT/ 051 CERTIFICATION _ Property Address: LALkb 5mq-"JC� Name of Owner 5t �� OSTC#.\)(kL4_,Address of Owner: Q.0, gdx lb�a Date of Inspection: ` ,�,+ / , �/ OS�tN�tl�,t U`1r4 Name of Inspector:(Please Pri )! [ a a,1 l H/ ELK C) 1 am a DEP approved inspector pursuant to Section 15.!340 of True 5(310 CMR 15.000) Company Name: � r. 3`r t �k v ;`ram u &..% r in l�cc E F Marring Address: ,., + Telephone Number: Tj p ) L 7-5;z CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 74 Passes _ Conditionally Passes _ Needs Further Evalu., 'on y e local Approving Authority Fails Q 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 thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner -shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS JUN 70%., 2 �999 >� le , r%, A 1 r revised 9/2/98 Page Iof11 _ `� Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirwed) "roperty Address: 4��+j x-Atbcx d Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 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. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times 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 r revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. .1 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure condi tions exist as described in 310 CMR 15.303. The basis for this determination is identified bel ow. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1,12 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any Port P or ion of a cesspool privy is within 100 feet of a surface water supply or tributary to a surface water supply. P Y . Any portion of a cesspool or privy is within-a Zone 1 of a public,well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Ad ress: 1.� Vo�1 �� — © • �e`. Owner: , Date of Inspection: / Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. x _ None of the system components have been pumped for at least two weeks and-the system has been-receiving twrmal flow ~1 rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Pk Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) The facility owner(and occupants,if differeru from owner) were provided with information on the proper x aintenanoa.af SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 1,1 g.p.d./bedroom. Number of bedrooms(design):dt-j Number of bedrooms (actual): Total DESIGN flow LALA 0 Number of current residents:-Z Garbage grinder(yes or no):�% - Laundry(separate system) Nis or no):�; If yes, separate inspection required Laundry system inspected 6e or no) Seasonal use (yes or no): Water meter readings, if ava table (last two year's usage (gpd): fV Sump Pump(yes or no): I — Last date of occupancy: a.-�1 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other t APPROXIMATE AGE of all components, date installed Of known)and source of information: Sewage odors detected when arriving at the site: (yes or no)�d revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty A ss:re ��fb S�Irw V Owner: � : w Date of Inspection: 0 S j.7 / Gl 01 BUILDING SEWER: 6 (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: t�i LS (locate on site plan) Depth below grade:`0 Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: t ODCa!RJVL Sludge depth: tail Distance from top of sludge to bottom of outlet tee or baffle: d� Scum thickness: Distance from top of scum to top of outlet tee or baffle: 11 l q „- Distance from bottom of scum to bottom of outlet tee or baffle:_ How dimensions were determined: ILl�tl/al1�Al� comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet'nvert, stru tural integrity, evidence of leakage,etc.) GREASE (locate on site plan) Depth below grade:_ 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '1r� SYSTEM INFORMATION (contirwed) Iroperty Address: LAM, Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal_Fiberglass_Polyethylene_other explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:ts (locate on site plan) 1 J(Depth of liquid level above outlet invert:jV_j Comments: - f leakage into or out of box, etc.) ver evidence o g (note if level and distr'bution is equal, evidence of solids c rryo _ Vt NG �Qx�x It,.D� [�i�'rlQ.�l'Ju'7nv.� �Uv� N• \.A �—� � PUMP CHAMBER: (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,-condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r _ SYSTEM INFORMATION (contirwed) ,roperty Ad ress: Owner: K , r%CUj S Date of Inspection: Cv SI O ';Z- `�j- SOIL ABSORPTION SYSTEM (SAS):l(1 S (locate on site plan, if possible: excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits. number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, d psoil, ndi ' n of vegetatio etc. + CESSPOOLS: A% (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: 1�} (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.) M1K t{ revised 9/2/98 Page 9of11 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: �(h 5r( irt )weer: v Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) C6 ® L sec: � �t 3 1 oil l i i revised 9/2/98 Page 10of11 • Y t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty A ess: �� Owner: Date of Inspection: o S �)0.0L . NRCS ReportnameNt) Soil Type— --- Typical depth to groundwater_ __ - USGS Date website visited (L® Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope NO / Surface water-*&)o Check Cellar bt Shallow wells N r Estimated Depth to Groundwater�koFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record _ Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps r Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page II of II Commonwealth of Massachusetts Title 5 Official Inspection Form . - Subsurface Sewage Disposal System Form Not for Voluntary Assessments C 448 STARBOARD LN Property Address SULLIVAN Owner Owner's Name f information is OSTERVILLE ✓ ` MA ' 5-13-15 ' required for every page. City/Town State 'Zip Code. Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the _ C3 computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector r use the return key. D.A.BROWN INC Company Name -P.O. BOX 145 Company Address CENTERVILLE MA- 02632 won <Cityrrown State Zip Code 508-420-4534 ' " S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® 'Passes 4❑ Conditionally Passes ❑. Fails ❑ 'Needs Further Evaluation by the Local Approving Authority 5-13-15 t In pe s ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner: and copies sent to the buyer,;if applicable, and the approving authority. ****This report only descrlb t condiitigns.,at the time of inspection and under the conditions of use . at that time.This inspecttc does not address how the system will perform in the future under the same or different conditlon&oCuse: . .V t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M •'y< 448 STARBOARD LN Property Address SULLIVAN Owner Owner's Name information is required for OSTERVILLE MA 5-13-15 every page. City/Town State Zip Code Date ofInspection B. Certification (cont.) ' Inspection Summary: Check,A,B,C,D or E/always complete all of Section,D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR.15.304 exist. Any failure criteria not evaluated are., indicated below. Comments: AT TIME OF INSPECTION SYSTEM MEET ALL�PASSING REQUIREMENTS. FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED., ACCORDING TO THE CURRENT OWNERS THE HOUSE WAS FORMERLY USED AS A SECOND HOME FOR THE ORIGINAL OWNERS AND THEMSELVES EXCEPT FOR THE PAST 2 YEARS. AS BUILT CARD MEASURMENTS DID NOT SEEM TO BE VERY ACCURATE .' 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 det-rmined," please explain. The septic tank is metal and over 20 years old*oi�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): i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 } � 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments° M , 448 STARBOARD LN ` Property Address SULLIVAN Owner Owner's Name information is required for OSTERVILLE MA 5-13-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ; ❑ Pump Chamber pumps/alarms not operational. System will.pass with Board of Health approval if pumps/alarms are repaired. , B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): r ❑ broken pipe(s)are replaced ❑ Y El: '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 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 will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments'' s 448 STARBOARD LN Property Address SULLIVAN Owner Owner's Name information is required for OSTERVILLE MA " . •5t13-15F ' every page. City/Town State Zip Code =• "Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within. 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. - ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for'fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: , D) System Failure Criteria Applicable to All Systems:'" You must indicate"Yes" or"No"to each of the following for all inspections: , �. Yes No.El , ® Vt" Backup of sewage into facility or system component due to overloaded or clogged SAS'or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El Liquid depth in cesspool is less than 6" below invert or available volume is less; ® than '/2 day flow - t5ins•3/13 P Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 448 STARBOARD LN ' Property Address SULLIVAN Owner Owner's Name + f information is . + required for OSTERVILLE MA . 5-13-15 every page. City/Town State Zip Code" Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any-portion of a cesspool or-privy is within a Zone 1 of a'public well ❑ ® Any,portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than,5.ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.], ❑ ® The system Is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. 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: E) Large Systems: To be considered a large system the systern 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 tlie questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to Fa surface drinking water supply the system is locatedin a nitrogen sensitive area(Interim Wellhead Protection ❑ Area`-IWPA)or a mapped Zone II of a public water supply well. x If you have answered"yes"to any question in Section E the system is considered a significant threat, , or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate' regional office of the Department. ' t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official lnspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments• M , ' 448 STARBOARD LN Property Address SULLIVAN Owner Owner's Name information is required for OSTERVILLE '. MA _ 5-13-15'• every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ' ®` ; ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the`previous two week period? ❑ ® Have large volumes of-water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not ® E] 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? ® ❑: r 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: r Number of bedrooms(design)-,, 4 r Number of bedrooms(actual):- 4 per assessing DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3/13- Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 6 of 17 Commonwealth of Massachusetts 93 �G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments T; 448 STARBOARD LN ' Property Address a SULLIVAN Owner Owner's Name. information is required for OSTERVILLE MA' 5-13-15 every page. Cityfrown State Zip Code Date of Inspection' D. System Information Description: As per as built the system.consists of a-1000 gallon tank d-box and 2 trenches.'` •f. 2 Number of current residents: - Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ,A ; ' ❑. Yes El No Laundry system inspected? - ❑ Yes ❑ No•, Seasonal use? - ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): - Detail: 2013-------404 2014---------398 :. Sump pump? . 4 'El Yes- ❑ No Last date`of occupancy: r„. MAY 2015 t Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pd) Basis.of design flow(seats/persons/sq.ft.,etc.): rt } zGrease trap.presett? Q Yes Q No • F { • .. • . Industrial waste holding tank present?' ° �A° ❑ Yes El No Non-sanitary waste discharged to the Title 5 system? '' ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 448 STARBOARD LN " Property Address SULLIVAN Owner Owner's Name information is required for OSTERVILLE MA 5-13-15 every page. City/Town State Zip Code bate of Inspection , D. System Information (cont.) F Last date of occupancy/use: Date ; other(describe below): " General Information Pumping Records: Source of information: .debarros septic Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: `1000 gallons How was quantity pumped determined? tank size Reason for pumping: maintenance Type of System: ® , Septic tank,.distribution box, soil absorption,system ❑ Single cesspool w El Overflow cesspool ❑ Privy ❑ Shared system(yes or no).(if yes, attach previous;inspection records, if any) r ❑ Innovative/Alternative technology. Attach a copy of the current operation and y 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form : a_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 448 STARBOARD LN Property Address SULLIVAN Owner Owner's Name information is required for OSTERVILLE MA 5-13-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information:, 1999 as per as built Were sewage odors detected when arriving at the site? ❑ Yes--Z No Building Sewer(locate on site plan): • Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ' Depth below grade: 2 A f feet Material of construction: ® concrete ❑.metal-y ❑fiberglass: ❑ polyethylene ❑ other(explain) If tank is_metal list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ ,Yes ❑ No Dimensions: 1000 gallon Sludge depth: moderate t5ins-3/13 Title 5 Official Inspection Form:Subsurface_ Sewage Disposal System•Page 9 of 17 s. Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 448 STARBOARD LN Property Address SULLIVAN Owner Owner's Name information is required for OSTERVILLE MA , 5-13-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle , Scum thickness light Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle <. 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.): tank was purred for maintenance x Grease Trap(locate on site plan): ' Depth below rade` } . � feet Material of.construction: , ❑ concrete •❑ metal fiberglass ❑;polyethylene R other(explain): 7, Dimensions: Scum thickness ' Distance'from top of scum to top of outlet tee or baffle ' Distance from bottom of scum to bottom of outlet tee or baffle Date of,last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts' r .. - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 448 STARBOARD LN Property Address , SULLIVAN ' Owner Owner's Name w information is required for OSTERVILLE MA S-13-15 every page. Cityfrown State Zip Code Date of Inspection r D. System Information (cont.) ' Comments(on pumping recommendations, inlet and outlet tee o'r baffle condition, structural integrity, liquid levels as related to.outlet invert, evidence of leakage, etc.); ' Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: t Material of construction: ❑ concrete ..❑ metal ❑fiberglass., ❑ polyethylene .; ❑ other(explain): Dimensions: Capacity: gallons Design Flow: ^ _ gallons per day.' Alarm present: ❑ Yes ❑, No • Alarm level Alarm in working order: El Yes ❑ :No Date of last pumping: Date ; Comments(condition of alarm and float switches, etc.): 2. ;•- `*Attach copy of current pumping contract(required). Is copy attached? ❑'Yes' ` ❑ No` t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 ssachusetts Commonwealth of Ma Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 448 STARBOARD LN - Property Address SULLIVAN .. >. Owner Owner's Name information is required for OSTERVILLE w' MA 5=13-15 _ � - every page. Cityrrown State • Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): box level no signs of leakage or solid carry over d-box was viewed by camera `4 Pump Chamber(locate on'site plan): `. Pumps in working order: . ❑ Yes ❑ No` Alarms in working order. ❑ Yes. ❑` No! Comments(note condition.of pump chamber, condition of pumps and,appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. a' , Soil Absorption System (SAS) (locate on site plan, excavation not required): ! If SAS not located, explain why: although it shows an inspection port on the as-built one could not be found so level of ponding could not be determined ' t5ins-3/13' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 3 o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M SVB'eW 448 STARBOARDLN Property Address SULLIVAN �. Owner Owners Name - information is required for OSTERVILLE MA 5-13-15 " every page. City/Town State Zip Code Date of Inspection D. System Information (cont) Type: ❑ leaching pits` . number • ❑ leaching chambers "number: ❑ leaching galleries. .;number: ` ® leaching trenches numberjength: 2-30 ft ❑ leaching fields number,.dimensions. V ❑ overflow cesspool number:' innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r - Although as built shows an observation port it could not be found so level'of ponding could not be. determined _ • Cesspools (cesspool must be pumped as part of inspection) (locate on:site plan):'.} Number and configuration, Depth-top of liquid to inlet invert ' Depth of solids layer Depth'of scum layer. j Dimensions of cesspool , Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 448 STARBOARD LN Property Address SULLIVAN Owner Owners Name information is required for OSTERVILLE MA 5-13-15 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ; Privy(locate on site plan)::` I � Materials of construction: Dimensions - Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,'condition of vegetation, etc.): �>M e t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r ' Commonwealth of Massachusetts Title 5 Official Inspection Form ` s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5 448 STARBOARD LN _ Property Address SULLIVAN Owner Owner's Name A information is required for OSTERVILLE MA 5-13-15 every page. Citylrown State. Zip Code Date of Inspection, D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to, at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins r 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 , Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 448 STARBOARD LN z Property Address SULLIVAN Owner Owner's Name information is required for OSTERVILLE MA 5-13-15 every page. Citylrown State - Zip Code ..Date of Inspection D. System Information (cont) Site Exam: ® Check Slope' ® Surface water ® Check cellar n.. �. ® Shallow wells 4 . Estimated depth to high ground water: 10 . e r feet Please indicate all methods used-to determine the high ground water elevation: ❑ Obtained from system design'plans on record . If checked, date of design plan reviewed: date ❑ Observed site(abutting property/observation hole within.150 feet of SAS) ❑ Checked with local Board of Health 6 explain:, ❑ ' Checked with local excavators, installers-(attach documentation) " ❑ Accessed USGS database,-explain: You must describe how you established the high ground water elevation:.,' from original installation as-built card _ Before filing this Inspection Report, please see Report Completeness Checklist on next page.. ` r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Assessing As-Built Cards Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 448 STARBOARD LN Property Address _ SULLIVAN ' Owner Owner's Name y information is required for OSTERVILLE MA 5-1y3-15 every page.a e. Citylrown State Zip Code 'Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A;'B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information Estimated depth to high groundwater. _ f w Di ' I. m r • •Sketch o Se a e s Disposal.System either drawn on page 15 or attached in separate file ® 9 P , Y P 9 P A r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=167054&seq=_. 5/14/2015 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTA.BLE LOCATION SEWAGE Ii -VILLAGE t2jSj f�.3 t t - 'ASSESSOR'S MAP&LOT L'I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY \60QCdP1, LEACHING FA 2^ t } CILITY: sin_ tYPe ��i1- �1] -NO.OFBEDROOMS r BUMDER OR OWNER PERA[MRATE: _COMPLIANCE DATE: Separation Distance Between the:. t Maximum Adjusted Groundwater Table to the 0 Feet Private Water Supply Well and Leaching Facility (If any wells exist M site or within 200 f et of leaching facility) _ h Feet Edge of Wedand and Leaching Facility(If any wetlands exist =_ within 300 feet of leaching facility) Feet Furnished by k f ' .. a ♦- ., • t , • . fkl' Rt http://www.townofbam§table.us/Assessing/HMdisplay.asp?mappar=167054&seq=1 5/14/2015 TOWN OF BARNSTABLE LOCATION JS-tcLr bcx4 4 L n sujw*@E# s/' VILLAGE (>TerA.IV SSESSOR'S MAP&PARCEL �'S NAME&PHONE NOf�L0f_ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _U\[,�k e (size) 10 NO.OF BEDROOMS -1 OWNER SO i VC A-V\ PERMIT DATE: ATE: P 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 - . r r r J F f f r r r f f r i r r r r.r r r f r f f f f J r J J r J r f f f f F r f f r ! . - - •. f F F-J F J J f / / f F f f f Back f f f f J f f f f f f f J f J Yard ` 13 42 34 TOWN OF BARNSTABLE LOCATION SEWAGE # VU.!-.AGE t-Q k � ti_.�. ASSESSOR'S MAP&LOT I�� ZL .II3STALLER'S NAMEy&PHONE NO. SEPTIC TANK CAPACITY \c)C0 '\ ' LEACHING FACILITY;(type) 2 1 (size) 2jo* "NO.OF BEDROOMS BUILDER OR OWNER ATE: �\T1c1 COMPLIANCE DATE: Separatton'Distance Between the: t Y t T ' r , �.. Feet - Maximum Adjusted Groundwater Table to the Private Water Supply Well and Leaching Facility (If any wells exist site or w t within 200 fc_ of leaching facility) `� � eet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 1. (J 6� ' Feet Furnished by • lr ' ; aa) _ f� � 'a ., �4�� ��_ �'l� ��� �' � 1�� �Z- `3� �C2- `Z g3- 3y' �•�. Sy`�0�� gy Sb4 `6 L �oYLs � � g �.c,`L,, , •. SESS S MAP NO. �PARCEL Q 10 c 1QK SEWAGE PERMIT NO. -VILLAGE Ile- [ MST A LLEVS DAME ADDRESS 9 U I L D E R OR OWNER DATE C 0 M r L I A N C E ISSUED `� ` A S a I -a � o 0� ,r I `s r ASSESSORS MAP NO: �g No.. 1" PARCEL NO: _1... FEB ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH To wti .... - .....-.-._....oF-.... , ppliratiou for Dhipogal Works Totmt `uetiort Vrrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: —+—e, Location-Address or Lot No. Owner / Address a ..�T ......!, . ......................................................... ---------------•---•-- M Installer Address ���O�/, Q Type of Building Size Lot....__..t............-.....Sq. feet Dwelling—No. of Bedrooms........... ...........................Expansion Attic ( ) Garbage Grinder (L-`T aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow...............`'`........._..._._.._..•._gallons per person per day. Total daily flow. .....''¢45.........................gallons. 9 Septic Tank—Liquid capacityZ�Oe_'-.gallons Length k.4.'...... Width_--41 -_---_____-__-_ Depth..:5F�.is Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No-------�---------- Diameter-------�_¢/.... Depth below inlet..... R......... Total leaching area..f !Lsq. ft. z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by.._ ...... ,.... --------- Date.N��._.. .. Test Pit No. 1..4_ -___minutes per inch Depth of Test Pit...z�4 ...... Depth to ground water_-_"_l08 u f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------------------------------------------•---------------------------------------------------------------------------------------- ... O Description of Soil-----o_°�:. 6" Wao�l�„g �` 5v�3. :So�G. /; v/,�i.✓�� ----••---••-••:-•-------•----------------••---•-•------•-•--•• --•--•------.._.........-•--- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------•--------------------------•-----------------------•------------------------............--•-----••-------------------------------------•------------------------------------------------. ---- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of iT"LE ;of the State Sanitary Cede 'The undersigned further agrees not to place the system in operation until.a Certificate of Compliance has beerYis d by hard of health. Signed = ............... ........................... �d Date Application Approved B - --•-.. ............. ` " 7 PP PP Y•-••--•---- . fi•�- Date Application Disapproved for the following reasons:.............................................................................................................. •-•--•••...•-•••••--•----.....-•-•••--------••----•••---•-•-------------••--•-•-------•--...••----------. ------------------------ - - -------------------------------------------------------------- Date { Permit No......�i._.7_-.. �--------------------- Issued..........................................Dat-------- Date No.15F�$....,2..!. ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ApplirFation for UWVosal Works Tontrnrtion Frrmit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: OFF L1!VLAAG_ a57Z--,;-Z(//l..G ................................................................ ............................. _..__._....__..........._..._._......_.._..._...._......__. Location-Address 1. or Lot No. �A � G-"�sT dt//s ..--------•---._....._......... ......... ----•------....•....------......---------._.... --•-..................._....��N.. ......._...---------..._..............._...-- /�� Owner Address -------------------------- Installer Address � 07� Type of Building �r Size Loth____.f..................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (� aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) A4 Other fixtures ...................•-•-•------------••••--.........•. W Design Flow.............. ._._...._._.._..____gallons per person per day. Total daily flow.........4��..4-.............._.._.._gallons. WSeptic Tank—Liquid capacit/ �?_..gallons Lengthf��G.......... Width`.'4.;/.... Diameter________________ Depths/.!;�O/­`-- x Disposal Trench—.\To. .................... Width_..__............ Total Length..................... Total leaching area....................sq. ft. Seepage Pit No........ Diameter......Z'¢__..... Depth below inlet...3............. Total leaching area_-'`^--'7/-_6....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by._ °i p..___ .:._. ` ._...._._. DateA��y..__? �`�¢ f---------------•---- 1_4 ,� Test Pit No. L��_. ____minutes per inch Depth of Test Pit..s3 Z........ Depth to ground water___"'.....e$..__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----•------------------------•-•--•---•--------........--•---.......-----•-•--...------ ..... O Description of Soil.... k/oopCa✓},j �' , �L3--SeI,.c 3!S'" /3 z " M&v /,c,.vL . ------•---------•-.........•-••--------•-•-•---•••-----•--•------•--•--•-••--------------••----• --- -------------•-------- x �!/D ----------------••-•-- UW --------------------------------------------------------------------------------------------------------------------------------1--•--•--•--••----••-•--••-------••-•--------------••......_......._. Nature of Repairs or Alterations—Answer when applicable............................................................................................... •-------------------------------•-------------------------------------------------------------------------- •---------------------------------------------------------------------------- •--------------- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of TI-1 j of the State Sanitary ode The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be i ed by t oard of health. Signed N. L -----------•-------- f �/�/ �..._.7 Date Application Approved By------------U =^"�y ...................... .......... .--- t� '-5--J Date Application Disapproved for the following reasons:............................................................................... ----•-._ .............. ----------------•---.........----...------••-••_.....•-•-----...-••••-••------•........-----------••-•--•---•---•---••--••••••--•---------••--------••-----•-•--•----•-•------••-••------••----------- Date Permit No..... 7 ��' --------------------- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T?�t` "�....... ................................................. ................................ Ter#ifiratr of TompliFanre THIS k TQ CERTIFY, That the Individual Sewage Disposal System constructed p -or Repaired ) by................ J %' ------- '°�- .-------------•. j ` �Yr'J nnstaller 1.�- CF - lC V `--' 3, ...... ----- at ,_...... has been installed in accordance with the provisions of TI T IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... ........... dated-----------------_________-._____-_-.._••_.._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7aurn/............OF....... BYO.-�--'•-'•�-=/'•--- FEE.. .3...... Disposal Works ��%'5onstrurtiolt Vanfit Permission is hereby granted......... IA�a..•-----.. ............................................................................. ..__ to Construct (o**") or Repair ( ) an Yndividual Sewage Disposal System =t No.-----------L-a.1. `.....---- _f'- --------------------------------••-- ` ...._._. - -•..................^ _r Street as shown on the application for Disposal Works Construction Permit No-- ......... Dated......_................................... .....................................• -- ------------------------------------•---- oard of Health DATE............. _.�.. _ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS r V l:1 faI � ICtll',l1. 1 .._....__ ___�1. 1 f ,-•—�----- -..__--- Complcted by . - �►: o HIGH GROUND-WATER LEVEL COMPUTATION S i to L a c a t ion: oF� -5� 8o/�i� ��� 0s7Z7ZViGG�� Lot 140 #¢ Owner: S. &qcl, •J"7Z Address: DL7./Ni S A;F4 55 Contractor: Address: Notes: STEP l Heasure depth to water table 9 to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. i/12184 a date STEP 2 Using Water-Level Range Zone and Index Well Map locate . site and• determine: 'ate index wellTs/r✓ 89 . . A) Appropriate B) Hater-level range Zone STEP 3 Using monthly report"Current Water Resources Conditions" determine, current depth to water level for index well . . . . . . ///84 mo yr STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current depth to water level for index well (STEP 3) , and water-level , zone (STEP 213) determine water-level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP 5 Estinale depth to high water by subtracting the water- level adjustment (STEP 4) i from measured depth to water level at site (STEP 1) . _ . . Figure 3 :� � -7- TOP OF FOUNDATION 1 , CONCRETE COVER CONCRETE COVERS r i^✓ k /G n "e 4' CAST IRON .' . OR SCHEDULE 402 MAX � 12"MAX ' 4' SCHEDULE 40 PVC.(ONLY) P.V.C. PIPE PIPE - MIN. LEACH PITCH I/4"PER. PITCH 1/4"PER.FT PIT PRECAST I LEACHING - °-e E INVERT Z INVERT INVERT • PIT OR INVERT SEPTIC TANK EL.. /�,¢� DIET. EL. ,q j= _;; EQUIV. �\ BOX .r .K e' EL /4 ,7/ GAL , INVERT INVERT W W :i. 3/4"TO I I/2 `r EL.' " I' u-� WASHED w .' STONE 6'DIA, �, ` o PROF) LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM Ste; NO SCALE 71 Act inpt Vi us ♦r.►�c�•A;: L, per_ r /,✓ rN4' tatiAGH AQi 1 SOIL LOG ,¢�- -V � V WITNESSED BY : .- .}. =.A.<74, DATE ^��`� / '' TIME 1� 30 qy .�/FFaRL., A, BOARD OF HEALTH \ TEST HOLE I TEST HOLE 2 A,�s � f ,k:�rZCe')/ . . ENGINEER ELEV io ELEV. _ _. `� Soot DESIGN DATA -- NUMBER OF BEDROOMS TOTAL ESTIMATED FLOW '' .`: GALLONS/DAY rr >� BOTTOM LEACHING AREA SQ.FT. /PIT/C VVA ac SIDE LEACHING AREA SO.FTJ PIT/Jz9 GARBAGE DISPOSAL yE`-'. (50 % AREA INCREASE) `Arw TOTAL LEACHING AREA SQ.FT ` PERCOLATION RATE MIN/INCH LEACHING AREA PER PERCOLATION RATE .y. J y SQ.FT/G f'L. ( �� � -- - NUMBER OF LEACHING PITS L'- . . . . wig I \ D� v W k Ems' fxt' Fn ,� `� � of ..t77►��E' oN <}u, s S + ,ro . . . . . . . . . . . . . . . . . . ' L r R{ ur' r ! `D 'iZ ( / E. FD . xp Tv P. r _—— I ( --,, /Z sc19 _vp ` ELINi�. 41 E7- AE:�--4e-4-y L.9T✓v Sv.eV�Y c�3 � �.�r,��-1/•fAQu�D /1fig.SS_ A107�- D pN A 7Z>po ��YN /5Y CB9x7-- e- /v�4c� i I