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Home My WebLink About0046 TANGLEWOOD DRIVE - Health 46 Tanglewood Drive ` v q= 121 —057 Osterville ur Id a ° ° n , s ° n ; n ry . ° dD ° o - o , o 0 n " di E �f u n L ° op ° oc ° ° ° a ° ° e •a . ° " Q „ , . a n W Y A a a ° yry tic ° +0 4 o p 4 4Ad n Ymm a , v Yt v ^� p ° P o M< `b o n ° A7P awn a 4 ii��SSkk �q`g`1� ,. - ° a °°. ' ° ° � .� °.8 m t. ,�'°. _ •° � - . �11. py ° �4vt�r Ce� _ �aQ o. °�'. mite ."'� ar� -.w; imP., a" ,o 'n s �n °off it, ° n F c Commonwealth of Massachusetts °� J 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments LJ 46 Tanglewood Dr ` L- Property Address f , Carolyn Tata Owner Owner's Name / information is Osteryille ✓ MA 02655 01/28/2021 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. fmngoutf rms A. Inspector Information SI 1512-1 filling out forms on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road rr� Company Address - Teaticket Ma. 02536 City/Town State Zip Code r 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5' (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 01/28/2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.71/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is Osterville MA 02655 01/28/2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a precast leaching pit with stone. At the time of the inspection the leaching was dry and no visible failure_ criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is Osterville MA 02655 01/28/2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No i ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate yes or no for each of the following for all inspections: Yes No ® ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description; Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2020-75,000 gallons were used and in 2019- 147,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I ' Commonwealth of Massachusetts +� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7f26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ,i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 24"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: H-10 1000 gallon Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle.was in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tan lewood Dr v Property Address Carolyn Tata Owner Owner's Name information is required for every Osteryille MA 02655 01/28/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 T_anglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Oil 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7,126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r Commonwealth of Massachusetts �P Title 5 Official Inspection Form hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 t I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner, Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the leaching was dry and no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ,4 TF4uGtE�.o��` ' 7 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osterville MA 02655 01/28/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7!26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Tanglewood Dr Property Address Carolyn Tata Owner Owner's Name information is required for every Osteryille MA 02655 01/28/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist, Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached I For 15: Explanation of estimated depth to high groundwater included r e 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3> �< 46 Tan lewood Drive. Property Address Yury Shamritsky • Owner Owner's Name information is ✓ required for every Osterville Ma. 02655 12/06/2016 page. Cityrrown State Zip Code Date of Inspection CA Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere key the return Name of Inspector Y Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number umber , 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 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority „ -� 12/10/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or 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 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 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0�# Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •p� 46 Tanglewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This home has a H-10 1000 gallon septic tank a H-10 D-Box and a precast leaching pit.At the time of the inspection the leaching pit was d B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and.if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 6 Official Inspection Form:Subsurface.Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tan9 lewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required)for every Osterville Ma. 02655 12/06/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Drive. Property Address — Yury Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. Cityr own State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No. ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Drive. Property Address Yyr Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. Cityrrown 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. ❑ 0 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 p Y a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply i ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Forth: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 46 Tan lewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 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 ❑ ED Were any of the system components pumped out in the previous two weeks? ❑ Z 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. Z ❑ 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 t5ins•3/13 Title 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 46 Tanglewood Drive. Property Address Yury Shamritsky Owner Owners Name information is required for every Osterville Ma. 02655 12/06/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information,in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: ?✓�e2o/6 �/�, v,x� ��/�1�,✓l werc. cis Zti o2Ol v� ��//�vi G✓erc dte`/ Sump pump? ❑ Yes No Last date of occupancy: 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? ElYes ElNo Water meter readings, if available: t5ins-3113 Title 6 Official Inspection Foam:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46�wood Drive. Property Address Yury Sharnritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. Ctty/Town 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. 4 ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts _ Title .5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 03/11/1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 33" 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): 24" Depth below grade: feet Material of construction:, ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard H-10 1000 gallon 311 Sludge depth: t5ins•3113 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 46 Tan9 lewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required for every Cisterville Ma. 02655 12/06/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness V. Distance from top of scum to top of outlet tee or baffle 35" Distance from bottom of scum to bottom of outlet tee or baffle 5" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet.and outlet tee or baffle condition, structural integrity; liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local septic pumping Co. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions:, Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 L Commonwealth of Massachusetts Title 5 Officia l Inspection t• on Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 46 Tanglewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y [I 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.): i 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `< 46 Tanglewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. City/Town 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 0" ` Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tan lewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ 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.): At the time of the inspection the leaching pit was dry. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I J Commonwealth of Massachusetts . Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tanglewood Drive. Property Address Yury Shamritsky Owner Owner's Name information is required for every Osterville Ma. 02655 12/06/2016 page. Citylrown 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.): i Privy(locate on site plan): Materials of construction: Dimensions Depth of solids r Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I { t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v�< 46 Tan lewood Drive. Property Address Yury Shamritsk Owner information is Owner's Name required for every Osterville Ma. 02655 Cityrrown 12/06/2016 page. 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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 17 TOWN OF BARNSTABLE LOCATION_ 44 `C'A Nbtp �2 SEWACE '7S VILLAGE Ocl�V ASSESSOR'S MAP 6 LOT / 1�O✓r -�12- INSTALLER'S NAME A PHONE NO. -,5 a . ��,•7^ G.a 6�3 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO.OF BEDROOMS— -PRIVATE WELL OR PUBLIC WATER j trc. BUILDER O OWN$R 14I L4-41 4/42e�c/ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ( — VARIANCE GRANTED: Yes No • . . �A.c,it. o� l�� —Tp.�d� 35� Commonwealth of Massachusetts Title 5 Official Inspection Form orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tan lewood Drive. Property Address Yury Shamritsky Owner information is Owner's Name required for every Osterville Ma. 02655 12/06/2016 page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with-local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show five plus feet of seperation t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Tan lewood Drive. Property Address Yury Shamritsk Owner information is Owner's Name required for every Osterville Ma. 02655 12/06/2016 page. DPW I own 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 G,-c,,� e- i /3 o-rr om v-r A s 5 V tJ t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposalsystem-Page 17 of 17 COMMONWEALTH OF'MASSACHUSETTS EXECUTIVE'OFFI;CE-OF ENVIRO.N:MENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL_PROTECTION TITLE 5 OFFICIAI;INSPECTION FORM, NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A :CERTIFICATION Property Address 46 TanQlewood Drive �) Ostervtlle MA 02655 . . Owner's Name: Phil Warren Owner's Address: . l Date of Inspection. - December 22 2007 Name;of Inspector: (Please Print) James M. Ford Company Name: :. James M.'Ford Mailing Address: P.O.-Box,49.: Osterville MA 02655=0049 Telephone Number: (50J8 862-9400 CERTIFICATION STATEMENT , . . I:certify that Lhave personally inspected the sewage.disposal'system at this address and that the information re below is true, accurate and complete as of the time;of."the inspection. The inspection was performed based on perted 1.training and experience in the proper function and maintenance of on site sewage dtsposal systems. lt am a DEW f3 approved system inspecto.r.,pursuant to Section 15.340 of Title.5(MO CMR 15,000): The system:" - ✓ Passes ". Conditionally Passes e ds2 FurtherEvaluation by theL'ocal Approving Author ty c sJ� r ail - m Inspector's Signature: Date: December 31, 2007 The system inspector Shall su it a copy of t is 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.sent to:the:buyer,if applicable;and`the approving authority..' Notes and.Comments **.**This report only describes conditions at the time:ofinspection-and under the conditions of use of that time. This inspection does.not address how.the system.will.perform in the future under the"same or different conditions of use..: Title 5 Inspection Form 6m/2oo0 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS -SUBS URFACE RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)' Property Address: 46 Tan zlewood Drive Osterville MA. Owner's Name: Phil Warren , Date of Inspection: December 22 2007 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 ofxhe failure,criteria described in 310 CMR 15.303 or in 310 CMR 15.304 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.. Answer yes,no or not determined(Y;N,ND)in the 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 hnminent. 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 it is structurally.sound,not.leaking and'if a Certificate of Compliance indicating that the tank is less than.20 years old is available. ND explain: { 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(§).are.replaced obstruction is removed distribution box.is.leveled or replaced ND explain: The system required pumping more than times a'year due to broken or obstructed pipe(§). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced: obstruction is removed. . ND explain: Page 3 of l l OFFICIAL INSPECTION FORM'-NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION (continued) -Property Address: 46Tan zlewood Drive Osterville MA Owner's Name: Phil Warren . Date of Inspection:_ Decernbei^22 2007 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 Hea lth de termines in acc ordance with 310 CIVIR 15.303.(1)(b)that the system is not functioning in:a manner which will protect public health,safety and the environment: Cesspool or privy is within.50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2 System will fail unless the Board,of Health(and Public Water Supplier,if an de termines eter P. � y) mines that s stem is fun the - system Y func tioning m a manner that protects the public health,safety and environment: The system has a septic.tank and soil absorption system(SAS)and the SAS iswithin 100 feet of a surface water:supply or tributaryto`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 aseptic 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;watei~analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Tess than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other:...: . 3 Page 4 of 11 OF INSPECTION FORM-NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION. (continued) Property Address: 46 Tanglewood Drive Osterville MA Owner's Name: Phil Warren. Date of Inspection: Dec unber 22 2007 D.—System Failure Criteria applicable to all systems; You must indicate-either"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 : p or cess ool ✓ Static liquid level in the distribution box above outlet invert:due to an'over c loaded or cesspool logged SAS or ✓ Liquid depth in cesspool is:less than 6"below invert or available volume is less than''/z dayflow ✓ Re wired pumping mo re ore than 4 times p 1? . g in"the last year NOT due to clogged or obstructed pipe(s): Number of times pumped ✓ Any,portion of the SAS,cesspool orprivy is below high ground water elevation. — ✓ Any portion of cesspool or privy is within100 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. ✓ A'ny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no-acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP.certified laboratory,.for coliform,bacteria and volatile organic compounds indicates.that.the.well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria. are triggered. A copy of the analysis must be attached to this form.] No (Yes/No).The system fails: I have determined that one:or more of the above failure criteria exist as described in,310 CMR 15.303 _therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered'a large'system the.system,must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no".to each of the following: (The following criteria.apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area:IWPA)or a mapped . Zone II of a'public water supply well If you have answered"yes"to any question in Section E the.system is considered a significant threat,or answered "yes"in Section D above the.large system has failed. The owner or operator of any large system considered a significant threat.under Section E or failed.under Section D shall u rad et pg he system in accordance with 310 CMR 15:304. The system owner.should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 46 TanQlewood Drive ° Osterville MA Owner's Name: Phil Warren— 'Date Date of Inspection: Decennber 22 2007 Check if the followin have been done: You must indicate" es"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 7 ✓ Was:the site inspected for signs of break out? ✓ _ Were all system components,excluding.the SAS,.loeated 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 ofsludge 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: Yes No — Existing information. For example;a plan at the Board of Health. f Determined in the field(if any of the.failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 f Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN SPECTION FORM PART_C SYS TEM E M.INFORMATION Property Address: 46 TanQlewood Drive Osterville MA Owner's Name: Phil Warren Date of Inspection: December 22'2007 RESIDENTIAL FLOW'CONDITIONS. Number of bedrooms(design) 3 Number of bedrooms;(actual): 3 DESIGN flow based on 310 CM 15.203(for:example: 110 gpd x#of bedrooms):Number of current residents: 2330 Does residence have a garbage.grinder Is laundry on a separate sewage.system or no): Yes g y (yes or no): -La" [if yes separate inspection required] Laundry system inspected(yes or no): No'. Seasonal use(yes or no): No Water meter readings; if available(last 2.years usage(gpd)): Unavailable Sump Pump(yes or no) No Last date of occupancy: Currentl occuvied COMMERCIAVINDUSTRIAL Type of establish ment: hme nt Design.flow(based on 310 CMR 15.203):` d Basis of design flow(seats/persons/sgft,etc.): gp t Grease:trap present(yes or no): Industrial waste Bolding tank present(yes or Non-sanitary waste discharged.to the Title 5 system(yes or no) :Water meter readings,if available: . Last date of occupancy/use: -------------- OTHER(describe):," -GENERA L INFORMATION Pumping Records Source of.information:_ Puinned after inspection for maintenance Was system pumped as part of the inspection(yes or no). No If yes,volume pumped: _gallons--How was quantity pumped determined? .Reason for pumping: TYPE OF SYSTEM Septic tank;distribution box,soil absorption system Single cesspool . Overflow cesspool Privy Shared system(yes or no) (if yes,'attach previous inspection records,if any) Innovative/Alternative technology: Attach a copy of the current operati .obtained.from system owner)- on and imaintenance contract{to be Tight Tank Attach a copy of the DEP a - Other(describe): approval Approximate age of all components,date installed(if known)and source of information: Date of installation 3/11/92. Per built Were Were sewage.odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTIWFORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM.INFORMATION continued- Property Address:. 46 TanglewjLo _4Drive Osterville M4 Owner's Name: Phil Warren Date of Inspection: December 22 2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:. cast iron _40 PVC other(explain): Distance from private water supply well or suction line: _Comments(on condition of joints,venting,evidence of leakage,etc.): EPTIC TANK ✓ (locate on site plan) Depth below grade.: 22" Material of construction: ✓ concrete _metal _fiberglass -._polyethylene _other(explain) If tank is metal:listage: Is age confirmed by a Certificate of Compliance(yes or no), (attach a copy of Certificate) Dimensions: _ 1000 gal. Sludge depth: '2". Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" 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: 10 How were dimensions determined: _Measurinz'stick Comments(on pumping recommendations, inlet'and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,"etc.): Tees were present. The liquid level was even with the`outlet invert There did not appear to be any si ns ofleakage The tank was numbed fot maintenance GREASE TRAP: None(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: Colrunents(on putriping recommendations,inlet and outlet tee or baffle condition;structural integrity,liquid levels as related to.outlet invert, evidence of leakage,etc.): 7 f Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPO SAL.SYST-S YSTEM INS PECTION. PART SYSTEM INFORMATION(continued) Property Address: 46 TdnQlewood Drive Osterville MA Owner's Name: Phil Warren Date of Inspection: December 22 2007 , TIGHT or HOLDING TANK: None (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: allons Design Flow: allons/day Alarin present(yes or no): Alarm level Al arm in working.order(yes or no); Date of.last pumping: Continents(condition of alarm and float switches,etc): DISTRIBUTION BOX: ✓ (if present.must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Coi7unents(note if box is level and distribution to outlets equal,any evidence.of solids carryover,any evidence of leakage into or out of.box,etc.): The D-box was clean. 1J6 solids.were resent. PUMP CHAMBER: - None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 . Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: 46 Tan lewood Drive------------- ' Osterville MA Owner's Name: Phil Warren Date of inspection: December 22 2007 SOIL AB SORPTION,SYSTEM(SAS): ✓ (locate on site plan,excavation not required) ------------- If SAS not located explain why: :Type ✓ leaching pits,number:. 1-6'x 6'(1000 gal) Per as-built leaching.charabers,number; leach ing.gal leries,number: leaching trenches,number,length:; leaching fields;number;dimensions: ove rflow .flow c of number: , ber: Innovative/alternative system Type/name of technology: Conunents(note condition.of soil,signs ofhydraulic.,failure,lev etc.): el of ponding,damp soil,.condition of vegetation, _The leach pit had L of liquid on the bottom. There did not_yppearL to be anv signs offdilui e 'The bottom to grade was 13' A camera was used fog the inspection. The cover was 4'6"below grade CESSPOOLS: . None (cesspool must be pumped as part of inspection)(locate on site plan) . Number and configuration: Depth-top of liquid to inlet invert:' Depth of solids layer: Depth of scum layer: , Dimensions of cesspool: Materials of construction.' Indication of groundwater inflow(yes.or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site'plan) Materials of construction: Dimensions: Depth.of solids: i Comments(note condition of soil,signs of hydraulic failure; level of ponding,condition of vegetation,etc.): 9 s Page 10 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL';SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 46 Tanelewood Drive Osterville MA. :Owner's s Nam e: Phil Warren Date of Ins `ecti on: P Decenz. ber 22 2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two:permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. a a� ay 10; y Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION(continued) Property Address: 46 Tan lewood Drive Osterville MA Owner's Name: Phil Warren Date of Inspection:' December 22 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35+/- feet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design lan:re S. viewed:' Observed site(abutting property/observation hole p within 15 0 fee t of SAS ) Checked with Io cal.Board of Health-explain: TonoQranhic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-exp.lain.'. You must describe how you established the hi gh ground water elevation:on: Using Barnstable to o ra hic and water contours tita s the ina s were shown a site. roximatel 35'+/ to roundwater at this This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the systent will fatnction properly.in the future. There have been no warranties or guarantees, either expressed, written or implied, relating.to the septic system, tlie,inspection; this report and/or any components .of the septic system which have not been located and inspected. , 11 Town of Barnstable • �F 1HE 1pk Regulatory Services anxxsrnsie Thomas F. Geiler, Director .elf1639. Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work ConstructionTermit". If you should have any questions regarding this report,please contact the certified Septic- System Inspector who conducted the inspection. TOWN OF BARNSTABLE LOCATION i �An P�G+00 C Dr- SEWAGE# VILLAGE 041-mvA ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3 OWNER WA((V^ PERMIT DATE: COMPLIANCE DATE: 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 -*V S U T1 F a � a s A a � n a.s a a� ay 3 3s a6 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ApptirFation for Diipos al Works Tons' ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at � - ......_---. . � d.. .��v� ----- ................ .�-- ____ (� ----- . Lo io -Addre�ssA/ or D. . ..........-�� ....� ... ..................... • .lY.- . C........ .............� O Der Add'ess a l / Installer Address Type of Building Size Lot................:...........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( )- — Cafeteria ( ) Other fixtures -------------------------------- - w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.........._......... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................................0......................... Date....................................... aTest Pit No. 1................minutes per inch Depth of Test Pit..................__ Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 -••••••----------------------------•-----------------------------.•.....-...---.........--------...................................................--....... ® Description of Soil...............................................................................-------------------------------------=-------------•-------.........•••................ x U ---------------•-------••---------------•- W --•-------------------------•--••------ --•-----•---------•--------------------------•--••-----••••---••-•---- ----•- . - �s �� y� U Natu of Repairs Alterations—Answer w applicable _ L� ___ ______________j_____�! _ ........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha be issued by the board of health. Signed .......... .. ( Date Application Approved By ----------------------- -------_-------------_-----------------------------_---- ---------- Date Application Disapproved for the following reasons: --------------_--------.......................................... ............................................. ------------------I.-....---------. ------.....--------- ------------------------------------------------------------------------------------------------------------------- PermitNo. .......... -- -/--... -_---------_----- Issued ----------------------- ---------------------------...Date...-. Dare { No._�Na�.:. __ F�$ .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Uhiposal Works Tonstrnr`tiun ramit Application is hereby made for a Permit to- Construct ( ) or Repair (Y) an Individual Sewage Disposal .System at / Lo tion-Address -�7 or t Nro. � i ? ► e�/----------------------------- � ,� ..............•-•---------------•••----•........_............•...............•. v' - . .......•- Installer Address Type of Building � Size Lot............................Sq. feet U, Dwelling—No. of Bedrooms................................•_...._.....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria W Other fixtures ............................................................... W Design Flow..........................._...............gallons per person per day. Total daily flow............................................gallons. o W x Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter-___ _-__-•--- Depth................ Disposal Trench No................. Width.................... Total Length.................... Total leachin--area....................s . ft. Seepage Pit No--_---------------- Diameter--------------:.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results -Performed by.......................................................................... Date........................................ �4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2............:...minutes per inch Depth of Test Pit.................... Depth to ground,water...................._.." M ODescription of Soil........................................................................................................................................................................ U ------------------------- •------------ •-------------------------- ------------------------------- -------- •------------ ----------------------- ------- U _ Natu��r�e.of Repairs or Alterations—Answer when applicable_s�� ..........-� ��_..�G .��..�1��-.5. Agreement:' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance been issued by the board of health. Signed . = %%J` '..- (.:...�... r 2�`f G�"d�$.. = -------------------- ------ Date b Application Approved BY --------------------- gV`U �'«"r � aO - / a Date Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- -----------------------_------------------------------------- ----------..................----------------------------.... ...---.................................. Date � PermitNo. ......... ...E` .......1.-�_.. .....--- -----... Issued ........................................................--------- � Date �rtt R' THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH y; TOWN OF BARl!..��NSTABLE GertifiratP of U ornplin-nCE THIS IS TO CERTIFY, That t'e Individual Sewage Disposal System constructed ( ) or Repaired ( �✓ ) by �/�� -5...-/ 5 y '�.' a. ..... ' �• ------....................................--- •�` / � Installer / at « .. .........! A/�' tvv.N .../ - ......--..y G6 .. ----jy�`,q---'----------------- - ..................has been installed in accordance with the provisions of TITLE 5., of he State Environmental Code as described in the application for Disposal Works Construction Permit No. ...........,� a -. ........... dated ................................................ �a THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE'THAT�THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ... � -' Inspector . -----------�.`. ..,N THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r' TOWN OF BARNSTABLE No..... .`..l..... FEE ............ Disposal Works Tuntrnr#ion Vamit s � Permission is hereby granted -:�/.t. .... .......:-...........................................•---..........._ to Construct ( ) or Repair ( p)/an Individual Sewage Disposal .System A"Wl Street Cc�� as shown on the application foroDisposal Works Construction Permit N al.. a75~_. Dated.......................................... ............................. ............................................................. _ ^��' ^/ �..................................... Board of Health DATE-----------------------------------•- FORM 3115138 HOBBS&WARREN.INC..PUBLISHERS p/o f P/07ti . . Lof \ #,-ka ty H /1J) Qs -�-?/t V i 90; y93 fojrr O zy� ` lJ O O \ Saar j / kisfiv(,, t. s 7Y, 9l - 43 Ot.e- B y D. . lv.►o or. - _ f I TOWN OF BARNSTABLE LOCATION ` (v TA-06-LgWoof,� t�2 • SEWAGE`# -7S VILLAGE O�lS'T'�vL V I �. ASSESSOR'S MAP & LOT—La/ ®✓ INSTALLER'S NAME & PHONE NO. -.i(-,S i5a&5 Co,-- i; SEPTIC TANK CAPACITY 4060 LEACHING FACILITY:(type) h7l (size) Oo e;, NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER' BUILDER O LL.i�/P &-J411P- / DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Lc VARIANCE GRANTED: Yes No J u �l�o� l7 ./ 3:5� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t✓.CJ._.... -- ..OF.........G�.c.�f:r>:1 .� f�.. Appliration -for Uhopooal orko Tonfitrurtton Vrrniit Application is hereby.made for a Permit to Construct (11<or Repair ( ) an Individual Sewage Disposal System at: / j� ......-...... s?�,X11 (IIC� ��.---tiF�f_2 ------••------•- a - - ..' x � �1.. / /-----r. Loedtiio/n-Address ..�• --,�. 97 or Lot/No. _ .. lC [-II--- -iso•'�°6. .. .._. i' ` .Iyi.+T-�C�� y� Owner A dres ` a �Il � ------------•----------------•-•--• ...... ice--° 1� �•--= .......� ---------- Installer Address U ----A-_Type of Building �-+ Size Lot...��................Sq. feet Dwelling—No. of Bedrooms--------- cP...............--Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of persons.-______---_--_-__.___---.-- Showers ( ) — Cafeteria fixtures -------------------------------------------------------.......................................................................... .................... WDesign Flow.......... n1...................gallons per person per day. Total daily flow-------------------------------------------- WSeptic Tank—Liquid capacity.;c�_-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 ( ) Dosin tan ) O�� 19C12" i2— /j- 77 `-' Percolation Test R21, Performed by...�,& �. l �. .dr�,�-�a:..._... Date_~_/.. .n�f:-_7.7 Test Pit No. _____-minutes per inch Vepth of 1 est Pit_______________ _ Depth to ground water............ ........... !7, Test Pit No. 2................minutes per inch Depth of 'Pest Pit.................... Depth to ground water........................ --•------------------------------------------•----•--••-•-•-•-----............... ..... O -- Descri tion of Soil �r ��--- -�/ x �/\'� --- -- U �r�V -��. W 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 Article XI of the State Sanitary Code—The undersigned further agrees not troplace the system in operation until a Certificate of Compliance has been issued by the board of health. /Y v`��, e �6ad f iaD,A9` SI Date Application Approved BY = � ,-........................... --- ---�,'S Q`:---Tl--�----- Date Application Disapproved for the following reasons:...........................•--•-•-•• --•---•---••-•-----------•-•-•---...---•--•-----•------••----•---• ---•---- I ---•---------••--------•-•-•-•--•----------------•--••--------------•----•••---•--•••--•-••---......................................................... --------------------------------------------•--- Date Permit No. E--•--•-------------- Issued.---J- 1 -�----•---•-•------•---•--. Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ._.. ......OF...._.... c.%.��.�F�. .�................................. AV43liration -for Uiipuiittl Workii C owitriart4in Prrmit Application is hereby made for a Permit to Construct ( e<or Repair ( ) an Individual Sewage Disposal System at: _ .........--- jc:�1 .Z�.Allvrc/-. �t-"�M�---------------------- ----------------- Location-Address �r or Lot o. Q . Owner Addresses... a ------ � S�-��M --•-•--r.��'� ----- ...... ---------- ----- --------- Installer Address UType of Building Size Lot..... !!---------------Sq. feet Dwelling—No. of Bedrooms---------------��-___-------.____Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4Other fixtures ------------------------------------------------------------------------------- ....................... --------------------------------------------- WDesign Flow......... .. . .. :...................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity!.rV).gallons Length_______________ Width................ Diameter__-----_-.---_ Depth.-..----_------- x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area---------.----------sq. ft. Seepage Pit No----_c_+< ------- Diameter.................... Depth below inlet.................... Total leaching area------------- ....sq. ft. z Other Distribution box ( ) Dosing tank_( ) � /' /��• /- aPercolation Test Results Performed bY._.:-- ---------(_•:_.('Zfr1- :Z_....._ Date...:. ......... Test Pit No. -_-_-_minutes per inch Depth of "Pest Pit........r`_.._. Depth to ground water--------.-_.A_-.__._---- 44 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--.--._--__-._-.---_- - W -•----------•--------I-- ............................................. --•-------------------•--...----------•-----7.-.1---------.-.---•----•.-r..._-/----•-•--•-•••--=......••-•••---. ......... .......... Descrp ton f Soil----- � - - '-- ' -------------- -- / --•-'•-----••------- .... -G: ._.." ------ ---, W p•iy --------------------------_---.---......------------------•----------••-----------•--------------------------------------------•------------•--------•--.----.-------_----------•---••---------•---- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place-the system in operation until a Certificate of Compliance has been issued by the board of health. /r�.�ll�s Si ed------ !'T �'•_::.f /�i ,•_. -.-- ,fs--------------------- •-•--- / Date Application Approved BY 6 -----------f % ? 1 a v -%, �L- ` l • � .. , Date Application Disapproved for the following reasons:_______________.-------------------•-------•-------------------------_---_------------•. -------------- .........................................•---•----------------........ •-----------•-•--------------------------------•----•----------•----------------------.-----•-------_------------------•----_----- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !� OF......... ��-�rlLs' ,/...d.lac.,..r............................ �rrtifirate of Tlompliaurr TUI.S IS'TO CER=IIFY,I hat the Individual Sewage Disposal System constructed or Repaired ( ) 1 by......-....---r .. ....... .. �,./. ... ---------- ----------- - /� Installle I 1 -:.: has been installed in accordance with the provisions of _Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No - -----�`f-________________ dated-.... '_-_ C>_"_._7 ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------_-- L/---_ .�-------------•---•-------- Inspector-------- . THE COMMONWEALTH OF MASSACHUSETTS � BOARD OF HEALTH �! / — -- / No. FEE---- .................... BinVwial forkd Tonfitrurtion Prrmit l Permission is hereby granted..........! = 3?-'s._-=...... -------------------------------------------------------------------------------------•----- to Construct ( f'S o�Repair ( ) an Individual'yS[ewage Disposal/System at No...-----4�.___'' '.r=_�=r_r_ /.,z.f. -"`• j 1 Street as shown on the application for Disposal Works Construction P.e mit �______________ _ Dated.. - . ..._ ---- ,--- ---�:---✓ �.0 -1- - $ DATE...................•------ZD-1. _ oard of He FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS GArZ-k94r-r-- Gizi,.roE=%z N L� F lAw = 110 x 3 = 33b G.F.V. uSte- l aoo A,L- � 5215.P0S4,-L PIT - uSE tocxo C,4,L-. SOG.0 ALL AV-EA = L5o G.P. �> I ISo St= c 2.S = t;7S (;;I.F7.r). Bcrr T om AQUA= SF. TOT,&L ESIGtJ = 425 G.RTJ. Tt>TpL 1DatLNf FL44t/ = 33D 6.PD. ex tom\ 1-dGDl4TlOt.l tZl�T� ��Iu 2M1� Oiz GAc. 1 ,�kitt ay.aE WtLLtAM W%RM+Z+ f fi�tfi*tYY�� OL � . rS {-IOU Sol 4a' T1=sT �./z19.77 LU14N1 "�:ve i000 flnc + ; tuv, `fiL.o sto1.501t. 4' 1p � IW. G,aL. 9�,9 tNv. TA W IC IOaO as•1 tiwv. -4 - L%AcH PIT ! WASUED H � STO►J'E'+'�f 1 C>r�Tt1~1i~t PI.bT• L b Cf.►T 1 U t-.1 . �cTi 0 t t��.�f I Lt-L H� GOAL to 5 u o u,� b,o.,-tv 3 .z-s No ruR TOO- 1 G M tz T t t"l{ T►-1 A T T N T S"ow u Pt.A►J R 1"c=R �.i c C t-t ti.l:?t�2JIJ Gc��Pt_�(S �/ 1't't-2 TNT 51�� LI►-aE: Awb e>C•rptiCtC T•NC - owLi of- GATC-,• _ YZ" lam—' t G..!C.. czcGCS rc�:�v i�u� Su�v`Yut�� TNI�, C7C_Ati-I i�, a1�T L;A�,CC� 0a4 A.►J 0>TEG'�11t_lC o /GCr�Si St.I;C�'?Jt✓tC=1.[i >cJ;_�/l `Y Tt1ir C,�i=r,5r--re, 140wL- > Qf�t�t_lGl�.tJT I LL kM 5 SEWAGE PERMIT NO. J 7 VILLAGE I N S T A LLER'S AME & ADDRESS BUILDER OR DATE PERMIT ISSUED DATE CO-MPLIANCE ISSUED . _ .� �< v � _ � - � l � ��, � � ,�� , , �� Fxs... � /� d No.,...................... .........._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �.6u9". . ...........:..OF...... �!Q3.ST cP'.. ........................................... Appliration for Biipmiittl Workii Tomitrnrtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .. i' NG�� ............� .------....2=...... ................................... .......................................................... n Location-p6ddress or Lo No. l.. ...`.�....... -- ..�.1 c-1 c...- .................................................Ow Address <l_5.c ... -------------------------------------- ----------•--••••••------•-••-._. 1...--•-•-------...........------...............----•- a .........-- Installer Address U Type of Building Size Lot... .......Sq. feet .� Dwelling—No. of Bedrooms.._____... Expansion Attic (((fQ) Garbage Grinder (AAJ P`4 Other—Type of Building .l'� ....._._.. No. of persons.......$— ............. Showers (.2 ) — Cafeteria �e//�j Q' Other fixtures ---------------------------•--•• • .. W Design Flow...... .........................gallons per person per day. Total daily flow.......3 .........................�gallons. WSeptic Tank—Liquid'capacity/�Q Length-..), -a Length_.. _c�...... Width........4....... 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 ( ) '" Percolation Test Results Performed by.._._..�t//&..._-- w�—-------------- Date......3 =7 ....... 04 Test Pit No. 1... .�...___minutes per inch Depth of Test Pit.......2-......... Depth to ground water.._...d v --.._ . f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ....--:••----------------------------------------------------------------------••---------------•---......................................................... ODescription of Soil ."R2 t T ... ....................----•---•-•--------------•----------------------------------............._.. x ..........................................-�......._..Kns Wi�C...- `4-a (� _ Vfi1 --------------------------------------- '__1. ......... _� _._: �.`! .u?_�tc � ` ------------_------------------•------•------------.-----------•--- 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 issued b®y the board of health. �Signed.. lX..�:1.1 -l-�-I�- ..................... D 07 Application ApproveV --------------------------- - ...••_. .......................................Application Disapproowing reasons:.----•----------------------•-•-----...............---------...------------......------......••......_._........ .................................... ...............---•--------...------.............................------........................................••...."Da.............--- Permit No. D- -�� ........................ Issued.....13........? 7g ...................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) MP�C C DATA ` �i ` a 11 No.D •�f,.:•t. Fps.._.`......�............... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ..............'...rl: ..............OF......�r..................................• ;— � �, ..-----.... ......................... Applirtttion for Diiipoiial Workii Tomitrnr#inn "rani# Application is hereby made for a Permit to Construct )•'or Repair ( ) an Individual Sewage Disposal System at: Location_Address or Lot No. ......-- --•-..__...........••-•••••••...................... .......••• ...._-•-•.... ..._............................... Own�y Address --••--------•---0t >� -'--i........................................................ ................................................. Installer Address dType of Building Size Lot.__)...... .:r.`_ ........Sq. feet U Dwelling—No. of Bedrooms........:?________________________________Expansion Attic (,O6) Garbage Grinder (Ak.) aOther—Type of Building _..O1 J..._...... No. of persons.......�................. Showers (1 ) — Cafeteria (116) Q' Other fixtures .................•-••------_....- - W Design Flow........ ._r....._.__.__________________gallons per person per day. Total daily flow......... ........................gallons. n: Septic Tank—Liquid capacity e-Q'...gallons Length---.i r _._.___ Width...... ....... Diameter........ ...... Depth..... ...... Disposal Trench—No. .. «.!U�:___. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( � ) Dosing tank ( ) Percolation Test Results Performed by..___.. & ........_._ ...._..:.:. .................... Date...._..' ...r.....:........ ,tea Test Pit No. 1...!.- .....minutes per inch Depth of Test Pit.. ......... Depth Depth to ground water.._1J.. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Pd O t•' --• ........1 -__r-Description of Soil. " . •-----•---•--•••-—I ,,="'...`.............•--•------- 4st 1...................................... ` W .............L_ . .. ..l. .--_•l........ Y 6tct../1 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 issued by the board of health. Signed ref............................. = .�i /t, Application Approve " f "' / PP PP Y f Date Application Disapprove o e following reasons:............•---•-•-------------•---------------------••----------------------------•-•---......-----•.._---••- .......... • .•-•••----....---•••----• Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF /,. �. Tnr#if irtt#r of Tomplittnrr THIS IS TO CERTIFY, That the IndividualSewage Disposal System constructed ( ) or Repaired ( ) by ............. .............•--•-........-••----•-•---•---••----••--- ------- ._...---------- .._......--------•---------_-..-._....-------------•-• -•-- Installer at........................ !...................._........_._�________r`___._______._._.__._____.':: ..................................................................... ..._.______________... has been installed in accordance with the provisions of TILE 5 of h ate Sanitary Cod {as s� 'bed in the application for Disposal Works Construction Permit No.___G.•-f =_._, _. .... dated_.....��. �................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUA ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. la— aB - H � tjAe4 DATE Inspector....- COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �...�...T'' �..{.......OF...................... �i r', r t...j........................................... No -r._..°27.... FEE..... ........... �i��n�ttl ork� �on�#rnt##ion rruti# Permission is hereby granted............ /...........a C to Construct ( V)or Repair ( ) an Individual Sewage Disposal System j at No - i.....' ----- ...... A Streeter+ as shown on the application for Disposal Works Construction tPe Oit .................. Dated.......................................... �f L Board'of Health DATE !AV--- FORM 1255 A. M. SULKIN, INC., BOSTON f � t L.C.G. �' 358o I B • 5�41=ET 1 of 4- _—ter L,T i ��/r1CANT To Q'cR-�1/V AA k q0 , �.0.RZ. qb I-76.41 01b 6'xlo�i.gr`II't 01�" re•rw,,.i / STrFu� f- _�,9Z15 S.FP � Q21•} _ -�-1 ti �t•� oP' Dw eu..l LV= a r Rt � Fwb EL O Q U to co.o - J ; D � � OQa D. D(tjQrvFs f+f vi EL=ICn.4.c r�3.03 (00-19 I A•21.„ qq — a i \JjOOD i o� (T=W&4 wATEIL) IS, o0o S, F I oo'w I DTI--I F. S. P>. ra R s. F? —— is 7=X isn Q6 ELEVAmcw &,r� (Z p OF ppokyset, e�vATic j �c�-r �2 oar ° N L,=>-r S -TArt6Lati./cocD0 bk,,IE- S 1W APPRa.iED s P�4RD C F ►' EALM-1 a nA,s AUNT SG4l. DA'T'E: 4•S-84 WsI EBY e329--nFY TPA-r THE PR=�� EFLLlS SJ�+./EY11Jf� ice- .Jn& IJ°, : 84 3Co BUlLNU6 S440Wo c J Ti-JlS PLA" cOLiFflQMS TO 7PF= lc:)w iw6 LAWS 2q MUs4asaT LAur=- DR,8Y'. J.Q,E of BAPLosTABLE, MASS. C�U'fEc�/11 I F, MASS., o�Ib32 Cp.IyY s. Q 4•Sr83 SLIEer I o� IL DAi>= RED LAUD �lb✓E`rbR 20 f=T, MII.1 Ljd� : IF EITHaP_ T-,-iE SE PI'(G -rto - k O� [FAC 1 a 1 w& P►-r Arar= mwnRLs 71-I A" 12" B Lam/./ G Ro -DE , A 24"�I AN►eFrm-a c=Lx=ka-r>= c=vM R SHALL B15 2,V C 6--{T -To C p-ADM— ( DA 1�/EWAYS ca 1c Q1=r� / 4 — f=x PSG PIP Au rRA 1-4 E �C AW DA�r I P C:-W c� E/ - M 1W. PITc1--4 1, l EL= I O I.5 pER- FT. ) 1 A G RA Dl= / GOB/E R CLEe41.1'SA Q D USED ►,� (' KF1 L L !_IC�L)1D LEVEL_- _ ' IQas� pIP1 / I �2)O eSAL. wAsHe . 5rouE MIN. PI�TC44' o I o 0 o e o e °. •,) X4 • PE;:P- FT. � ArIG TA�IC FIST• e e o e . • e e r • ' 80X ° ° ° e o S e o o • r � ° r 4c P.v.G, o ° e ' EFFi:LTIva r ° ' CEP rt-1 ' ' W P51-4 ED SToa-JC • ° e e • r . e • I � �o e 2.s = 4� I v/ • e e • e e e r PR�AST 5�1✓PAGE 188.5 x Pt"I oQ ��Al 1► \,/l=QT 1=L>=�/ATtOF JS �f�.5 x 1 . 0 -18 ./p o r r o 0 0 0 0 16-j\/!=QT AT BLS I L D wC-, �18.5 FT, ll (o F'T D/A.M. _ r T GA PPG 7* S4q /-/D I j IIJLJ=T St=pT►G TAIJ� 98.o FT. IO FT, DIAM. C t!gE TABuIAT�or.J) cK_r LET SE Pi'I G TA+._I K. 9 7.8 FT. _ I N LtT D 15TQ I Pxm O� �oX 9-1-0 FT• SF�C 1 t��! o F= G QCnLJW D WATE IL TABLE . ,<-T Cox 9 8 F=T• S1=wAG>= D ISPoSAL SYSTEM I u LET 1_EAG}-}1�16 PIT . G 5 Fr. LEA c"106 PIT DIME�r ->1cu A 3 FT. 'AI r a I p%MEN51 oe-4 , B FT. rJLJM R 2 o F P DQc�xnS 3 D 1 M Esi SIoU C_ 4 FT. GA-RBAGE DtSR�4L t�u,T I..so�I H �_�1 L LOG T(:DrT'A L EST7 M A'TED FL.,ow 330 6AL. lDAK -Sc>I L TEST Q l So I L TE=T W 2 `10 t L- 'T M-5T 1-1UMBl=P- of LEA,:f44Ir.16 P17 1 EL= 9aA ML ' �19. 1 of 50►L TEST MAQcN IL'7, 1984 SIDE L1=A�HIu6 PER AIT 169 F`T, o_,L LOAM ,L1-g Q�p r�:W JQE 6�FFaO-D peTT�M LEP�N I I_Jb 1L��T -IB FT. CERCG.XA_n=fJ P—ATB We. 1 L1=5S -T,0TAL. LEACHING t�2EA 2G,C,= SGZ. FT. ME_D PERa�LAnof-+ RA-rE "e 2 Ar-J L_EA—_Nr,._'. A4Z-A oCe 5Q. fT "j.c SAND SA AA E I L 71=sr Ke-F AS �SHOF ,y MED- �� LoT S TALJe.LEWmD OF �P AS 8'_12 FINE -t-nN D s A` T y • �L1J5 �JL�vG�I1.1� If.JG. p � 'o-E L' 810.2 e L= 8 7• I 1q Mv��1cEG i=T LA s m, �I-iT�Q�1 LLE, MASS trio�cSe.(1 ��.lWb WATER Eucc IEPT-n «Irco�tr : 13p FsID� L�,4T>a : 4.5.84 Np SURVE �111RI1ft\p es2L/�OUuD WA'TEQ.a EL LOCATION mow/& SEWAGE PERMIT NO. Z79 ,PILLAGE INSTA LLER'S NAME i ADDRESS , . T- 33 ��s ,�c��1 �I UILD \ER OR OWNER Y90,15 'c�� •v �, CGS. DATE PERAIT ISSUED DAT E C 0 M P L I A N C E ISSUED �. �� - s � y 3� Z� �v � # � ��. � b .. td l? _ _ apse.�