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HomeMy WebLinkAbout0138 WEST WIND CIRCLE - Health 138 West Wind Circle, Osterville i; i ` R p f, i y - o ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle !,p, v Property Address h`p Barbara Beriau Owner Owner's Name - information is Osterville t3 18 required for every � MA 02655 8- ^a page. City/Town State Zip Code Date of Inspection r 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. `p��uuunupp��� Important:When filling out forms A. Inspector Information / - �a3 .•��,�9:. sq -,, ��. ' ''•. �. on the computer, use only the tab James D.Sears JAMES key to move your Name of Inspector v SEARS 'Co cursor-do not Capewide Enterprises use the return Company Name key. 153 Commercial Street �``` r� Company Address nnnn� Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 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 8-4-18 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and"the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 138 West Wind Circle �LrT Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 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: The system is a 1500 Gal. Tank D Box and pit. 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): f 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 �V 138 West Wind Circle Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle u Property Address Barbara Beriau Owner Owner's Name information is Osterville MA 02655 8-3-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form _ la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle V Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth ingINOW is less than 6" below invert or available volume is less than 1/2 day flow hf K ❑ ® 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 ,p Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle Property Address Barbara Beriau Owner Owners Name information is required for every Osterville MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .,u 138 West Wind Circle Property Address Barbara Beriau Owner Owner's Name information is required for every Osteryille MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2016-111,000Gal g ( y g (gpd))' 2017-59,000GaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .,V 138 West Wind Circle Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town 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) II Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA. 02655 8-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the 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: 1987 Permit #87-763 18-20-18 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 22" i 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.): Pipeing is 4" PVC SCH - 40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form aI e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle �V Property Address Barbara Beriau Owner Owners Name information is required for every Osterville MA 02655 8-3-18 page. . City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0e Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at V below grade w/cover's 6". In and outlet tee's. No sign of leakage or over loading. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 138 West Wind Circle Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town 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: 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 ale Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle •V Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-20" below grade w/one line out. Box is New 8-2018. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form FIo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vtt 138 West Wind Circle Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: 1 ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle �u Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Pita Pit at 6' below grade w/cover at 2'. 18"water in pit w/no sign of over loading or solid carry over. No high stain line. 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle �V Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts _ Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A-i=3�` ° 03 3 = Y3 � A- 3 t5insp.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 tI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle �V Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N12,611 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 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: T.H.on design 12.6' no G.W.. Bottom of pit at 8'below grade. Bottom of pit at 4'above T.H. Depth. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �= Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 138 West Wind Circle Property Address Barbara Beriau Owner Owner's Name information is required for every Osterville MA 02655 8-3-18 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 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. g O` % ^ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitation for MispoSal *pstrm Construction 3pPrmit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System 2,Individual Components Location Address or Lot No. 13$ Weser to (00 61k, Owner's Name,Address,and Tel.No. Map/Parcel ®� GAROARA Or;2lAU Assessor's Ma p I �l l�a ®f 13% We'-t- W aii) CiP, 05-rand( Installer's Name,Address,and Tel.No. ®$'- -'Y°Z— Z'P Designer's Name,Address,and Tel.No. 7497 &_&q1SXP0 l5 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Qom(D)Z t'AG No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) N ff gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) XM:S(Y".A_ (T-tf L z)Wk- AA)b cam - ro;-r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea Sign Date 7 "' Application Approved by Date J—a s(�� Application Disapproved by Date for the following reasons Permit No. 9 oC Date Issued ;z^I ^� _---------------v—= .¢+e6._,.ygr-may_..,, Y .., .• .:y. "4 �]R.. - � '.F. • 'Y IY+•' -,_ - _.-: _ _ _ _ >--s--" w>w.:^.+.,*..lT.i4,.�%..:,:.n.� •t:... '"s-w€�� v "n„w,. .-i•�,.. ^�",.�"w .v-..Fi.a,+•r^�Rx+..^w`�''+" �•..��wu....rr•vYa�.r�.v.EG",r,,'s...¢ 'may.`•-•.. '7 } No. �; Fee THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ' 2pplitatlon for Disposal.-* 'tenl Construction 3permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) «°El Complete System Ondividual Components Location Address or Lot No. 13$ Vje;T- (A)(µfb e—J&# Owner's Name,Address,and Tel.No. /Parcel GAR ewa(AU Assessor's Ma p i .t 0rt � ate' 9 Iti � wtAj el P_ Q t�Wt Installer's Name,Address,and Tel.No. 54$'-4 "'7*'M$S"Y j Designer's Name,Address,and Tel.No. . LJ Type of Building: Dwelling No.of Bedrooms j</ a t Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures , Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title .., Size of Septic Tank. Type of S.A.S. Description of Soil ,. I Nature of Repairs or Alterations(Answer when applicable) XN Slkt.t_ A11.3.e) Gcs(:j!tf �u !)Ab! a rAFt A4dti u Ltd 'Date last inspected: l �►1- P.bS"7a /1(1 t. C' ! t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. }} Signed Date �� • `I I } Application Approved by .d Date "( Application Disapproved by Date for the following reasons Permit No. r �� ( Date Issued '- THE COMMONWEALTH OF MASSACHUSETTS / BARNSTABLE,MASSACHUSETTS `Tp 2 e--J-11THIS Certificate of Contpfiante IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(K) Upgraded( ) Abandoned( )by �Ao�La(179_ ..OTWE M CEa l/" g at -I;4 R,'`AJ G -r (mil(A J I) C_f k Q S-r .- has been constructed in accordance with the provisions of Title 5 and the for Disposal System 1 Construction Permit No. dated Installer�PF-wih 1�J�'tx pros - d -Al) Designer R)1 #bedrooms - Approved design flow _ �-" '�: gpd The issuance of this permit shall not be construed as guarantee that the system will firnetrd'esigned. Date •.# Inspector � ________aa-u_ ____2_____________ _____________-_______----------------------------------- . E No. V Fee THE COMMONWEALTH OF MASSACHUSETTS Lrv�ir PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Permission is hereby gran ed to Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at wE757 - RAJ{ lb CIA424E and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. nc, Provided:Construction must be completed within three years of the date of this permit. Date. " It `1 Approved by z COMMONWEALTH OF N ASSACHL•SETTS .' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION l ONE WINTER STREET. BOSTON. NIA 02108 617-292-5500 WILLIAM F.WELD TRt'Dl'COXE Governor Secretan ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A LiE TIFI CAT ION Property Address: //3T G�7Q�l� �'•�d 6--• OS L&`.r 1`�Address of Owner.�� � Date of Inspection: 06�//l c7 _De^ (If different) Name of Inspector: f `�` I am a DEP approved system ins ector pursuant to Section 15.340 of Title 5 (310 CMR 0) r p Company Name: (�� ,y�-c p �wc�r't�a c_r. a—� RLCEVEO .� Mailing Address: -Pc:;, /.So< 2_5 g d l l�SN J�eQ v7 0 2� c) 10 ' Telephone Number: r ) ��- /.e{ 7 O J U N 2 5 1997 ' CERTIFICATION STATEMENT TOrOFpt ��VIJfHII�EPT I certify that I have personally inspected the sewage disposal system at this address and that the inio� on reported below is tr�ue;accurate and complete as of the time of inspec,;o�-.. The inspection was performed based on my training and Aw .ce in the propegr\tunction and maintenance of on-site sewage disposal systems. The system: ' Passes Conditionally Passes _ !seeds Further Evaluat v the Local Approving Authority Facts Inspector's Signature: Date: fo 1 The System Inspector shall submit a copy of this inspection report.to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web http:hwww magnet.state.ma.us/dep Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I�' ,���; Owner: Y "�C/-{ y Date of Inspection: B].SYSTEM CONDITIONALLY ASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ -The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass �,.din�'spec17ion if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 41 t C] FURTHER EVALUATION' IS REQUIRED BY THE BOARD OF HEALTH: r Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER .� WHICH WILL PROTECT'THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supn'y well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) I Property Address: 9' ._ fA 'a, 2..�� �� _ as�� v-•' l Owner. _ _ Date of Inspection: Dj SYSTEM FAILS:©61,t You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov;. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe!sl. Number of times pumped _. Anv portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Am portion of a 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 I of a public well. And portion of a cesspool or privy is within 50 feet of a private water supply well. Am- portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone ll of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: _ Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling .vas inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site �,+as inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened. and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owneri were provided with information on the proper maintenance of Sub-Surface Disposal System. "1 Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) [15.302(3)(b)j (revised 04/25/97) Page 4 of 10 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: _—j _ p-( kg C.. Date of Inspection: / 'r7 FLOW CONDITIONS RESIDENTIAL: Design flow. Sit g.p.d./bedroom for S.A.S. Number of bedrooms: 0- Number of current residents:bA Garbage g,,:der (yes or no):_ Laundry coronected to system (yes or no):-*S Seasonal use (yes or no;: VD Water meter readings, if available (last two (2j year usage (gpd): Nth Sump Pump (ves or no): Last date of occupancv COMMERCI.AL1NDUSTRIAL• Type of establishment: Design fiow:_galions/day Grease trap present: (yes or no!_ Industrial Waste Holding Tank present: ives or no)_ Non-sanitary v%aste discharged to the Title 5 system: tyes or no).— Water meter readings, if available Last fuze of o :-pa-c, OTHER: (Describe Last date of occuoancv. GENERAL INFORMATION PUMPING RECORDS and source of information: utv?(L V-4.1's tzT t, epeA QQM Q i L'!F:q aT Tr-,:s -Tt nr-, �_ System pumped as part of inspection: (yes or no) I"O If yes, volume pumped: eallons Reason for pumping TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Pricy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the,site: (yes or no)�JC� (revised 04/25/97) Page 5 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) �G/42 . � Property Address: W_%�X, c-�--� Owner: Date of nspect'on: BUILDING SEWER: }.]b (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction lire Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:1 (locate on site pl n Depth below grade: kr Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list, age _ Is age confirmed b� Certificate of Compliance _(Yes.'No. Dimensions (j� Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: �i _ Distance from top of scum to top of outlet tee or baffle._ at Distance from bottom of scum to bottom of outl t tee or baffie: k0A _ How dimensions were determined tktASu Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ZitG vQ GREASE TRAP:�- (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner:/"T— Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacm-: gallons Design floe: gallons/da% Alarm level. Alarm in working order_ Yes, _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: W 4, (locate on site plan; Depth of liquid level above outlet inver,: t�%� ��—� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) t;t PUMP CHAMBER:—t--X. (locate on site plan; Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,+ SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excava ion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:If 1,11( leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions. overflow cesspool, number: Alternative system: Name of Technologv: Comments: ( ote condition of soil, signs of hydraulic failure, level of ponding, conditi of vegetation, etc.) r �2J CESSPOOLS: �J(� (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN-FORMATION /(continued) Property Address: 1 Owner: ---A - Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house). YEN d i t X O AG hr4- SU `e)`\" 3y (revised 04/25/97) page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 4 Property Address: 3� (� S� , c.-- ox �--�- - v z,-- Owner.��� Date o Inspection: CP Depth to Groundwater �,_j Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board or health Checi. FEMA Maps Check pumping records Check local excavators, installers Use I_SGS Data r• Describe in your own words how you established the High Groundwater Elevation. Must be completed) ZU.S- �Qoto�.c� Jti�J� � �s L, �,1"v�3►�qp.�t-.�m5 t'� �. �� � �'"'r,� x (revised 04,25/97) Page 10 of 10 TOWN OF BARNSTABLE C LOCATION ���� G� SEWAGE # VL' LAGE OS'�'i `�—�_ ASSESSOR'S MAP &LOT/!1 I I C3 INSTALLER'S NAME&PHONE NO. :SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �g4 h `3g ' s i o �rl its. 3cl '��^ TOWN OF BARNSTABLE ' LOCATION SEWAGE # VILLAGE' St n _�r ASSESSOR'S MAP & LOT�� INSTALLER'S NAME.& PHONE NO. O'C SEPTIC TANK CAPACITY 1.-SCb qQ LEACHING FACILITY:(tVpe) 3 1 t (size qa X ' NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER r DATE PERMIT ISSUED: ` DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No hAAr-7 ' k A •YJ�i � p L/ IDoo T ct , t�ri, g-io No..S....'.. 111. C FEs.. �.`. ........... THE COMMONWEALTH OF MASSACHUSETTS ®� ARALTH ------'------.- _--- -----------------OF......................................................................................... Appliratioo for Biopooa1 Work.6 T000trurtion rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System t rjt2...... .......... .._... ---- --------- ---------------- -- . .... .. �'j"Location3 Address / or Lot No. It a�Up Owner Address _Y, Installer Address d Type of Building ,g Size Lot___---_ �. � -Sq. feet U Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building of persons............................ Showers Cafeteria ( ) QOther fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- W Design Flow.......= ___. -----j_/V---------gallons per person per day. Total daily flow.......... .. �-------------------gallons. 1:4 Septic Tank—Liquid capacity/' .gallons Length................ Width................ Diameter---------------- Depth................ xDisposal Trench—No. ................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.lo.���-yF'- Diameter......_$ .._..... Depth below inlet.................... Total leaching area...cz102.1...sq. ft. Z Other Distribution box Dosin t k ) i '-' Percolation Test Results 'Performed by. I .H ........ �62e_!U '--------------- ..... Date....... ....... Test Pit No. 44S.. sX"' . . y - trlmutes per inch Depth of Test Pit.__ �_ ___-- Depth to ground water. Test Pit No. 'niihutesper inch Depth of Test Pit...a.&C9..... Depth to ground water.A.-I. �+ -------------------------------------------------------•---------------.......---•-•--•----------- ................................................ 0 Description of Soil........................................................................................................................................................................ x U W ---------------- ---• -----------------------------------------------------...------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable................................................................................................. --------•------------------------•--•-------------•---------------------------------•----.........-•--••---.....--------------------•--------------------------------------------------....-•--•-...---- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of 7TILIE 5 of the State Sanitary Code— The undersigned further ag s n t o piacq-theeste�,in c� operation until a Certificate of Compliance has be issued by the boa�ofealth. ! d Signed ........ = ••• ------------ Date Application Approved By............. Date Application Disapproved for the following reasons----------------------------------•-•---.....--•--------•------•----------------••---------......----------...... .._•-----••---.-----••---------------•-....._._....------------------------------............-------•.-•... Q' Date PermitNo------t1.1----763---------------------- Issued....................................................... Date No....... ........ Fmc............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................I ..................OF..................................... Appliration for Uh3posal Marks Tonstrurtion "pamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .......la!?.; .....WA?­a'.X.....LU 74�.. . ... .................. ..................................................... Location-Address or Lot No. ..................... .......�........................................ .................................................................................................. Owner Address ........................ . ...... .............................. ...............................:.................................................................. Installer Address Type of Building 3 Size Lot____ . feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder 04 Other—Type of Building ... No. of persons............................ Showers Cafeteria 04 Other fixtures ..................................................................................................................................................... Design Flow............... ...................gallons per person per day. Total daily flow.................... ..........gallons. 1:4 Septic Tank—Liquid capacity1S.45,.,P__gallons Length................ Width._............._ Diameter.-.--_---_____-_ Depth___..__..._..._. 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----------ALM---- zii... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit............_._..... Depth to ground water--___-_-___-_-_.-.-----. G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_____-_-_-_ ---_- P4 ........................................................ - ---------------------------------- ----------"---------------• -------------- 0 Description of Soil....................................................................................................................................................................... ......................................................................................................................................................................................................... --------------------------------------------------------------------------------------------------------------......................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .......................... --------------------------------------------------------------------*--------------------------------------*--------------------------------------------------­------------ Agreement: The undersigned agrees to install the aioredescribed Individual Sewage Disposal System in accordance with the provisions of TITLIE, 4, of the State Sanitary Code—The undersigned further agle no to places the ystem in operation until a Certificate of Compliance has been issued by the board ofXe_a_1t_h) Signed.....a ............... ------ -------------------------------- Date ApplicationApproved By............... ---- ----------------------------- . ......... ---7........ Date Application Disapproved for the following reasons:............................................................................................................... .........................................................................................................I............................................................................................... Date PermitNo........ ...................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ic .......OF........ .................................... Trrfifiratr of Toutphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed r>eor Repaired by................... ...................................... ............................................................................................. 7 A 41 nst filer at. XW ------ ."................................................................................................ has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit NTo---02n...'74t-a............. dated.--_.._..._._.___...._.....___.._............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT if FIE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... ........................ Inspector...................... = .......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... . ........OF................ �.............................. FEE...21 .--...ems... Disposal Works Tonotrurtion "Pantit Permission is hereby granted......... . ------ .......................................................................................... to Construct ( or Repair aAntividual Sewage Disposal System X at \LTG............. ............k_"V_T......ZL--*,7.......... .. ........ Street as shown on the application for Disposal Works Construction Permit No..&5.L.Z�.. Dated.......................................... ....................................................................................................... Board of Health DDATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -6 6 W"t Wind end 0 pavement C-urr.Le Z7 Z ass 401 w! i,de ' 36,7 V 1-6.!x 6 Pit U/I I atone, U 33.0 pao�ite. 20 r l oo a� No Sca& =427 apd 1500� 40•0 I �3.4 ,a ,,} 43' 30' ��VT P Z I � 1 S00 3G•3 to" 3® i,, � G � m-3 PROPOSED 32' d N 54' a' 3c.3 33.7 .,'ot 26 .�'o.t 27 3$.7 z 8,872 S 9 3c. i o Adt Cope l 35. 49 lvaabOt, road 14ya.l r , Ma• 02601 34.4 117./3 3G.9 C 6 _ Scate I "-30� Date. 9-I 1-87 1 3/ u�c Sketch Ptan o� .c'and inOdte oiV-.e, Pia. ; No, ed�coom.� 2 904, gando, ph lVa4xaa. Ca2bb dim., no 13ei*4 tot 27 " shown on a plan itecoicded in ,�'each� a� 201 4. gat4 to te, i�ec�.i dt&q bk 290 pry SS. lze ve " 201 Revat i owi ahown a4z on an a.44u sed da tm. Capacity 427 qpd Beat l?" t#P-66 39 -------- trade 8-r9-87 ��te: A ---�'a✓� �e->5o�'0? � .. • wit. No wateA encouhte ed pr &s'd ?2 Twin. peh l ". 35.g 34s 3z.3 30.S p�c• u i OF A M S Icon e coc/vie NA OF,v 1" . ARD ti. KE. RN Y� u � ;7Cu2C� 7CWZCi da MtLNt �> v 6 0. �o sT BHA! ►A