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HomeMy WebLinkAbout0149 WEST WIND CIRCLE - Health West Wind Circl �, �1 Osterville P q A - 121 011037 Hwy ° ° e "r y] ° , ° " a A ° a = a o e =v 1 g w � , fl. e 3 Ike � F West Wind Circl Osterville P yq ' A = 121 011037 'k ra , J • i it# No. 4210 1/3 BGR o811�� 10%1 `. y o Orb Ir 1 :L� -� o Commonwealth of Massachusetts - # / cop�,Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 West Wind Circle ?roperty Address `I John McShane' Owner Owner's Name_' information is Osterville MA 02655 April 9, 2018 _ _ 0.. required for every State Zip Code Date of Inspection page CityrFown 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 A. General Information S l y 1.2 q q filling out forms on the computer. use only the tab 1. Inspector. key to move your cursor-do not Patrick T Sullivan use the return Name of Inspector key. Rea y Rooter Excavting Company Name — PO Box 89 Company Address Forestdale MA 02644 _ zip code City/Town State 50$-888-6055 SI 12843 — TeleDhone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority April 16, 2018 Inspectors Ign� attire 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 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. Title S Official Inspection Form!Subsurface Sewage Disposal System-Page 1 of 1+ C t5ins.Aoc-rev.6116 / TO I/J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page CityfTown 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replacea or repalrea. i he system, upon compietion or the repiacement or repair, as approved by the Board of Health. will pass. /� Check the box for"yes", "no" or"not determinedy(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years?id* 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,' ith a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspe�io n if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tans less than 20 years old is available. ❑ Y ❑ N ❑ D (Explain below): Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Pace 2 of 1- t5ins.doc•rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville MA 02655 April 9, 2018 required for every State Zip Code Date of Inspection page. City/Town 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 brorkenhsettled o water unevenlevel in distribution on box Systeme distributn box uwill to broken or obstructed pipe(s) or due to a 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 o 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 theBoard of Health: ❑ Conditions exist which require further valuation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. will ass unless Boa d of Health determines in accordance with 310 CMR 1. System p 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 ithin 50 feet of a surface water ❑ Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t5ins.doc•rev.6/16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page. City/Town S. 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: T- ** This system passes if the well water anal sis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no o er 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 El ® 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 flow Title 5 official Inspection Form.subsurface Sewage Disposal System•Page 4 of 17 t5ins.dor,•rev.6116 Commonwealth of Massachusetts �N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville MA 02655 _ April 9 2018 required for every State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool.or privy is within 50 feet of a private water supply well. ❑ 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 ppmt provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. ror iarge systems, you must indicate.either ryes or`,no to each of the foiiowing, in addition to the questions in Section D. Yes No / ❑ ❑ the system is within 44et of a surface drinking water supply ❑ ❑ the system is within 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is loca ed�in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or mapped Zone II of a public water supply well If you have answered "yes'to any q estion in Section E the system is considered a significant threat, or answered"yes" in Section D ab a the large system has failed. The owner or operator of any large system considered a significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 MR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 official tnsoection Form:Subsurface Sewage Disposal System.Page 5 of 17 t5ins.doc•rev.6/16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page. City/Town . Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® El available 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)] Do System Information Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms (actual): 330 GPD DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t5ins.doc•rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Nat for Voluntary Assessments 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Ost_eryille MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page. city/1-own D. System Information Description: 0 Number of current residents.- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes Z No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No 2016= 72 GPD Water meter readings, if available (last 2 years usage (gpd)): 2017= 84 GPD Detail ❑ Yes ® No Sump pump? January 2018 Last date of occupancy: Date Commerciallindustrial Flow Conditions, Type of Establishment: Design flow(based on 310 CMR 15.2 ): gallons per day(gpd) Basis of design flow (s/en .ft., etc.)-. ❑ Yes ❑ No Grease trap present? Industrial waste holdin ❑ Yes ❑ No Non-sanitary waste di Title 5 system? Yes ❑ No Water meter readings, Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17 t.5ins.doc•rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �.� 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Owners records: Pumped 2015 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 17 t5ins.doc•rev.6/16 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank and leach pit installed 02/18/1986. D-box replaced 02/01/2013. Certificates of Compliance on file at Health Dept Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): 1.8 Depth below grade: feet Material of construction:' ❑ cast iron 40 PVC ❑ other(explain): N/A Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan):. Depth below grade: fee_ 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 8.5' x 5' x 45 1000 gallons Dimensions: 4. Sludge depth: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 9 of 17 t5ins.doc•rev.6/16 Commonwealth of Massachusetts —. Title 5 Official Inspection Form Assessments -- - - Subsurface Sewage Disposal System Form Not for Voluntary Assess 149 West Wind Circle -- Property Address John McShane Owner Owner's Name information is Osterville MA 02655 April 9 2018 required for every State Zip Code Date of inspection page City(Town D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" 3" at inlet, <1" at outlet Scum thickness 10" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14 Dip tube and tape measure. How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet concrete baffles in place. Liquid level at outlet invert. Tank not in need of pumping at time of inspection. 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 s/um outlet tee or baffle Distance from bottom ttom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 t5ins.doc•rev.6116 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 West Wind Circle _ Property Address John McShane Owner Owner's Name information is Cisterville MA 02655 April 9, 2018 required for every page CityrTown State Zip Code Date of Inspection D. System Information (cost.) 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: j71 ❑ concrete ❑ metal ❑�ibe'rglass ❑ polyethylene ❑ other(explain): I 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 /armfloat switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No :5ins.doc•rev.6/16 Title 5 Official Insoection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - NOtfor Voluntary Assessments 149 West Wind Circle — -- . roperty Address John McShane Owner Owner's Name information is Osterville _ MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cone.) Distribution Box(if present must be opened) (locate on site plan): 0„ Depth of liquid level above outlet invert Comments (note if box is,level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet. No solids carryover. No high water staining over outlet invert. Riser brings cover within 6" of rade.. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump c amber, 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: Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 12 of 17 t5ins.doc•rev.6/16 Commonwealth of Massachusetts t= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 West Wind Circle Property Address John McShane -- Owner Owner's Name information is Osterville _ MA 02655 April 9, 2018 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) Type: 1-6' x 6'w/ I' Of ® leaching pits number: stone. ❑ 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 Liquid level 6"from base at time of inspection. High water staining 3+' below invert. 6 rows of clean stone visible in sidewall. No sign of past hydraulic failure. Riser brings cover within 6"of grade. 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 groundwat inflow ❑ Yes ❑ No Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 t5ins.doc•rev.6/16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of soiias E::: Comments (note condition o/igns draulic failure, level of ponding, condition of vegetation. etc.): Title 5 Official Insoection Form:Subsurface Sewage Disposal System•Page 14 of 17 i5ins.doc•rev.6116 L • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t a 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville _ MA 02655 aril 9, 2018 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cone.) 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 i I I 1 i I I I H l � i \AJ I c:N l 0�1` r 1 V) � � I i !Sins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 149 West Wind Circle , Property Address John McShane Owner Owner's Name information is Osterville page. City/Town MA 02655 April 9 2018 required for every State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ! ® Check Slope ❑ Surface water ❑ Check cellar i ❑ Shallow wells 4+' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: I ® Obtained from system design plans on record 4/16/1984 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: Test hole at;#166. 11/0912007. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: maps massgis.state.ma.us/oliver.php — `.ou must describe how you established the high ground water elevation: Test hole in 1984 found no ground water. Test hole at#166 found no ground water at 144" (elv= 25.8). Base of leach pit at elv= 32+-. Accessed local ground water contours and topo mapping. High around water at elv= 18... Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t5ins.doc•rev.6/16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 149 West Wind Circle Property Address John McShane Owner Owner's Name information is Osterville _ MA 02655 April 9 2018 required for every State Zip Code Date of Inspection page City/Town 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 t5ins.doc-rev.6/16 a®1 .3f03 � No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpiitation for Disposal 6pstem Construttiou permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System 5 Individual Components Location Address or Lot No., C-4,-2 3—? CU.44 Ct?'d Owner's Name,Address,and Tel.No.51:: Asses ssoor'sY Map/Parcel 0 Cam) C `P�gX. C'c T. ®� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 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 Nature of Repairs or Alterations(Answer when applicable) ��A I�'A�; �, �,[�- �C�.e.✓.�� w 1 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 Health. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Pe mit No. a 0 3" Date Issued --- - ----------------------- _---------------- 013 - b35 No. Fee THE COMMONWEALTH OF-MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes J 4plitatlon for Misposal 6pBtem Construction Permit 1 Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System Individual Components 4'> Location Address or Lot No. c 2 C t,J. C s t Owner's Name,Address,and Tel.No.5: 'p xaA \'a°� cv®-_ ,G ((P Assessor's Map/Parcel © C cA7.�. C;1` , �1 Installer's Name,Address,and Tel.No. Stz& '.'?7 k-- Designer's Name,Address,and Tel.No. `,,Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 14 Design Flow(min.required) A/ 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) 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 Health. Signed Date i Application Approved by It 5 Date 's 3 D- C3 i Application Disapproved by Date for the following reasons Permit No. a 01 3- 3 Date Issued 3 3 I l THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (ertifitate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at (�'(.`� (izi eT Cj__?� \A, C,J- , has been constructed in accordance a with the provisions of Title 5 and the for Disposal System Construction Permit No.d 0 13 63y dated Installer`C�,. cej cJ" Ce.C,� '1.� Designer #bedrooms Approved design flow gpd The issuance of this permit shall not bns4u d a a�gurantee that the system will function as d igned� Date ! 1 J Inspector -- - - ---_-- - - ._ _- --..- ,_._ - . _.. No. dGI 3 —035 Fee I� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(a Upgrade( ) Abandon( ) System located at 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. i Provided:Construction must be completed within three years of the date of this permit.�1 f� Date 3� l roved A b V` PP Y i Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M -,-1i20 est Wind Circle Property Address - Jim Casella t Owner Owner's Name . information is Osterville u. MA 02655 required for every 4/27/12 page. C� ity/town " State Zip Code _ Date of Inspection Inspection results must be submitted on this form. Inspection forms may.not'be altered in any , way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information - � .' , ' '. • , on the computer, use only the tab 1. Inspector: key-to move your III IT` I t cursor-do not Ricky Wright key.- the return Name of Inspector y B & B Excavation,lnc. rab Company Name + 14 Teaberry Lane - Company Address _ ° • � - e Forestdale, MA i 02644 Citylrown y State Zip Code ' 508-477-0653 S 14595 Telephone Number License Number f f B. Certification _ 7,J -- 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-ama DEP approved system jnspector pursuant`to Section 15.340 of Title 5(310 CMR 15.000). The system: El Passes : :F ® Conditionally Passes ❑ Fails *_ ; ❑ Needs Further Evaluation by the Local Approving Authority 4/27/12 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 DEP. 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 r the same or different conditions of use. t5ins•11/10 Title 5 Official Inspe i n F m:Subsurface Sewage Disposal System•Pageat of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 129 West Wind Circle r Property Address #` Jim Casella - aj Owner Owner's Name ° information is required for every Osteryille MA- ' 02655 4/27/12 page. Cityrrown State Zip Code .x Date of Inspection B. Certification '(cont.) r 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: 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. w ' Ej Y ❑ N ❑ ND (Explain below): :' Tank and d-box need to be replaced - t5ins•11/10 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 129 West Wind Circle Property Address Jim Casella Owner Owner's Name information is Osterville MA 02655 4/27/12 ` required for every - ' page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) a . 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 ❑ YY. ❑ N ❑. ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑.,Y. ❑ N ❑ ND{Explain below):.' p ❑ The system required pumping more than 4 times a ear due to broken or obstructed i e s` The, Y q P P• 9 Y P•P ( ) 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: ry ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 y 4 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form ' ., Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 129 West Wind Circle Property Address , Jim Casella Owner- Owner's Name information is Osterville M' MA 02655 4/27/12 - required for every ' page. Cityrrown ' 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: • F • i D) System Failure Criteria Applicable to All Systems: x i 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 4 , Discharge or ponding of effluent to the surface of the ground or surface waters; ❑ ® due to an overloaded or clogged SAS or cesspool El 0 Static liquid level in the distribution box above outlet invert due to an overloaded i . or clogged SAS or 99 cesspool P 00 0'y ` ® i. -Liquid depth in cesspool is less than 6" below invert or available volume is less F than '/2 day flow t t5ins•11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, M 129 West Wind Circle Property Address Jim Casella Owner Owner's Name information is , required for every Osterville MA 02655 4/27/12 page. City/Town State_ Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping.more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ®; Any portion of the SAS, cesspool or privy is below higli ground water elevation. ❑ ® Any portion of cesspool or privy is within'100 feet of a surface water supply or tributary to a,surface water supply. ❑ ® Any portion of'a cesspool or privy is within a Zone 1 of a public well. ❑ ®, Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 ❑ El +: pthe system is within 400 feet of a.surface drinking water supply " El El 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 .. r Area-IWPA)'or.a mapped Zone 11 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. f . t t5ins-11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts ' u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w k 129 West Wind Circle Property Address Jim Casella Owner Owner's Name information is required for every Osterville MA 02655 4/27/12 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No -❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any," f 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? ❑ El available 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 Boardof Health. ® Determined in the field (if any of the failure criteria related to Part C•is at issue approximation of distance is unacceptable) [310 CMR 15:302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for.example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 West Wind Circle Property Address ; Jim Casella Owner Owner's Name information is Osteryille =x MA 02655 4/27/12 required for every page. Cityrrown State Zip Code -,,Date of Inspection D. System Information Description: Number of,current residents. f ' 4 < r 0 Does residence have a garbage grinder? ,' 0 Yes ® No, Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? = c* ❑ Yes ® No', Seasonal use? : ❑ Yes ® No - Water meter readings, if available (last 2 years usage(gpd)): ; . n/a Detail , Sump pump? ❑ Yes ® No Last date of occupancy: c k. approx 1 year 3 ago Commercial/Industrial Flow Conditions: 6a • Type of Establishment: Design flow(based;on 310 CMR 15.203): 3 ti Gallons per day(gpd) Basis of.desigh flow(seats/persons/sq,ft., etc.): Grease trapresent? P ❑ Yes ❑ No N, Industrial waste holding tank present? ;, ❑; Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes•❑ No - Water meter readings, if available: t5ins•11/10 ° Title 5 Official Inspection Form:,Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts A . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 129 West Wind Circle Property Address Jim Casella f. Owner Owner's Name information is Osterville MA 02655 4/27/12 required for every page. City/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, distributionaboz, 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 DFP approval. Y ❑ Other(describe): t t5ins•11/10 M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System:Form - Not for Voluntary Assessments wM ,••° 129 West Wind Circle Property Address ` Jim Casella Owner Owner's Name information is Osterville MA 02655 4/27/12 - required for every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.). Approximate age of all components, date installed (if known)and source of information:, 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site-plan): f, 23" Depth below grade: feet Material of construction: ❑ cast iron ® 40,PVC ❑ other(explain):, ` >20 Distance from private water supply well or suction liner feet ° Comments (on condition of joints, venting, evidence of leakage, etc.): - At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank (locate on site plan): Depth below grade: 16" 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 57'x 57' x 8'6" Dimensions: , A Sludge depth: 4' t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts v ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. _ - F 129 West Wind Circle Property Address Jim Casella Owner Owner's Name , information is Osterville MA' 02655. 4/27/12 required for every `' - _ page. 'Cltyrrown 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 1811 Scum thickness 8 Distance from top of scum to top of outlet tee or baffle 11 ,. 5„ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? ' p scour stick - •s Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be leaking at the seam and must be replaced Grease Trap(locate on site plan): y Depth below grade:. feet Material of construction: ° ❑ concrete ❑ metal ❑ fiberglass- ❑ polyethylene ❑ other(explain): Dimensions: ',Y Scum thickness Distance from top of scum to top of outlet tee or baffle ' .+ Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17. r" Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 129 West Wind Circle F Property Address Jim Casella % Owner Owner's Name information is Osterville MA 02655 4/27/12 required for every page. Citylrown 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: t Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: ` gallons r „ Design Flow: * . r gallons per day. Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order:,, ❑ Yes ❑. No Date of last pumping: r Date , Comments(condition of alarm and float switches, etc.,):' , *'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 41 Commonwealth of Massachusetts r 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol untary"Assessments wM 129 West Wind Circle Property Address Jim Casella Owner Owner's Name information is required for every Osterville - MA 02655 4/21/12 page. Citylrown 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.): At time of inspection d-box is deteriorated and must be.replaced. No signs of solids carryover Pump Chamber,(locate on site plan): Pumps in working order:' r ❑;,Yes •❑ No Alarms in working order: El Yes ❑ No .b J Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required)_ If SAS not located, explain why: t5ins-11110, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 t Commonwealth of Massachusetts', Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 West Wind Circle Property Address ' Jim Casella . Owner Owner's Name information is osterville MA -_ 02655 4/27/12 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: P ® leaching pits number: - 9 . - ❑ leaching chambers ;a number: ❑ leaching galleries" number: ❑ leaching trenches: number, length'. leaching fields ` * number, dimensions:. k ❑ 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.): x 4 . At time of inspection leaching was dry,and.appear`s to be in good condition. No sign of•hydraulic failure ' Ile Cesspools (cesspool must be pumped as part of inspection) (locate on site plan) P Number and configuration Depth—top of liquid to inlet invert.- Depth of solids layer, 't Depth of.scum layer , Dimensions of cesspool Materials of_construction Indication of groundwater.inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pagee13 of 17e Commonwealth of Massachusetts , Title 5 Official Inspection Form { Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 West Wind Circle Property Address Jim Casella Owner Owner's Name information is Cisterville MA 02655 4/27/12 j required for every - page. City/Town State Zip Code • Date of Inspection D. System Information (cont.) . L Comments (note condition of soil;signs of hydrau,lic 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.): ' , s ti » 4 t5ins•11/10 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 , 129 West Wind Circle r Property Address Jim Casella r Owner Owner's Name information is Osterville MA 02655 4/27/12 required for every , ,page. Citylrown - State . Zip Code Date of Inspection D. System' Information (cont.) " Fl r 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 ly • * 'a.. � 3 Y• � it � '.. • . - t5ins-11/10. Title fi Offininl lnenwMinn Fnrm-Cr ihn On— ....ni-11 c.—e..,.o—.c„f 47 - Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, M 129 West Wind Circle Property Address + , Jim Casella Owner Owner's Name +' ' information is required for every Osterville MA 02655 4/27/12 page. Citylrown k State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar _ ® Shallow wells r , >102" r Estimated depth to high ground water: feet { Please indicate all methods used to determine the high groundwater elevation ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 4 Date : ❑ Observed site (abutting property/observation hole within 150 feet of SAS) . ' ❑ Checked with Iocal'Board of Health ❑ Checked with local excavators, installers-(attach documentation) ❑ _ Accessed USGS database-explain: You must describe how you established the high groundwater elevation: - Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins+11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 16 of 17+ • Commonwealth of Massachusetts r Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 129 West Wind Circle s Property Address ' Jim Casella T Owner Owner's Name . information is required for every Osterville MA 02655 4/27/12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist , ® Inspection Summary: A, B, C, D, or E checked t ® 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,, a Y 4 , ..f .. w - i ,gyp,. ' �" '\". •., ,�R.. ' # F lY. .� . .-{ t5ins•11110 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �013b��bWL 4 `t A a F � � • �` "` Town of Barnstable Health Inspector Office Hours Ft"E' do Regulatory Services 8:30-9:30 s Thomas F.Geiler,Director 1:00—2:00 * BARNSPABLE, MASS. i63q. Public Health Division 10 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601, Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE 1. �ener ert :ation: Size of ProP Y O 9 8 Address: LO (,(,Y CW Map Parcel d I I Q 3 7 Name: 0�19� & QRA-a' ..R-� Ok,. Phone#: SG _D 0-)\�� 2a. How many bedrooms exist at your property now? 2b. Are you planning to add.any bedrooms? VVo If yes, how ' an f y. �- 2c. How many bedrooms total are proposed at this property(including the esty un )? C > o' - 2d. Please include a copy of the floor plans for the entire property- showing the vxistirig rooms in the home plus the proposed amnesty apartment and/or'addition. Pleas&labeF each room clearly on the plans. Ln m , 3. Is the dwelling connected to public sewer? YES or. \jV0 If the dwelling isconnecfed�fo ublic sewer;,skip questions#4through#9below:` 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to (!PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 4 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- 610211bFOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this prope . Special Conditions: _ ND MIL i �T 3 ( a"^� (hC�rty Q,/health/wpfiles/amnestyapp I s` FI,� T � �5sbh c,, s ^ ~ d-. �C � �c �V U i .. '�.� r _ �' p�G(�5 � ����� U vG� _--- � �� =-f �� ��� � � � ���� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAiRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTA :AS NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM F ECEIVED PART A CERTIFICATION � J a JR222002 Property Address: TOWN,OF BARNSTABLE HEALTH DEPT. Owner's Name: Owner's Addre T ®2 Date of Inspection: Name of Inspect r: pleas pr i Company Name: Mailing,Address: f PARCEL 4=�_ Telephone Number: Q LOT CERTIFICATION STATEMENT I certify that,I have personally inspected the sewage disposal system at this address.and that the information reported below is true,accurate and complete as of the time of 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 pursuanXpasses ection 15.340 of Title 5(310 CMR 15.000).. The system: Conditionally Passes Nee Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Bate: 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP),within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This`report'only describes conditions at.the time of inspection and under the.conditions of use'at that .* n 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 6/15/20.00 page I 5 Y Page 2 of I I �1 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A C��E^^RTIFICATION (continued) Property Address: 09 GC✓ t Owner Date of spection: A0 c; Inspection Summary: Check A,B,C;D_or E/'ALWAYS complete all of Section D A. System Passes: J I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 3'10 CMR 15.364 exisi: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 substantiaFinfiltr'ation or exfltration or.tank failure is imminent.System will pass inspection if the existing tank is replaced with complying septic tank"as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup'or break out or high static water level in the distribution box due to broken or' obstructed pipe(s)or due to a'broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more.than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ' ND explain: 2 Page 3.of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM' PART A CERTIFICATION(continued) Property Address: Owner: Date of ection: 0Q - C. Further Evaluation is Required.by the Board.of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect.public Health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any).determines that the system is functioning in a manner that protects the public health,safety and.environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a: surface water supply or tributary to a surface water supply.. _ The system has a septic tank and SAS and the.SAS is within a Zone I of a public water supply. The system has a septic tank and SAS:and the SAS is within 50 feet of a private water supply well_ The system has a septic tank and SAS and.the SAS is less than 100 feet but 50 feet or more from_a. private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified.laboratory, for coliform bacteria and volatile organic compounds indicates.that the well.is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ,LI Owner: Date of pection: 000 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ ._V 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 V Static liquid level in the distribution box above outlet invertdue to an overloaded or clogged SAS or / cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow 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. �J. Any portion of a cesspool or privy is within a Zone I of&public well. _ t/ 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 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.] Ad (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,the.refore the system fails,The system owner should contact the Board of Health'to determine what will be necessary to correct the failure. 4 E: Large Systems: To be considered a large system the system must serve a.facility with a design-flow of 10i000.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 upgrade the system in accordance with 310 CMR 15:304.The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 12 Property Address: �c 9 (e P,,al I!tP/�y� Owner: " Date o spection: I PCB Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _L.,-- Pumping.information was provided by the.owner,occupant,or Board of Health V 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 backup /_ Was the site inspected for signs of break out? V _ Were all system components, excluding the.SAS, located onsite _ 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 m�tenance 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. 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 Page 6 of 11 OFFICIAL INSPECTION FORM—,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C' SYSTEM INFORMATION Property Address: ate, Owner: Date of ection: / 00 LOW CONDITIONS RESIDENTIAL. Number:of bedrooms(design):- Number of bedrooms(actual): 'S DESIGN flow based'on 310 CM 15.203(for example: 11.0 gpd x#of bedrooms): SSb Number of current residents: Does residence have a garbage grinder(yes or noj/di- ;r 1e ✓ Is laundry on a separate sewage system (yes or no .[if yes separate inspection required] Laundry system inspected yes or n Seasonal use: (yes or na " Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no : 7 6 c- Last date of occupancy: ffI n COMMERCIAL/INDUSTRIAL- /Vv " UIl1zU Type of establishment: . Design flow(based on 310 CMR.15.203): . gpd �\J Tj Basis of design flow(seats/persons/sgft,etc.): 4OP Present(y or no lnlr*e Grease trap es ):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: + Last date of occupancy/use: L OTHER(describe): wc./ ir 3 ae N0'"`I �^ / GENERAL INFORMATION CA iy H 0�, , Pumping Records Source of information: Was system pumped as paft of the inspection(yes or nop" If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ptic tank,distribution box, soil absorption system _Single cesspool �. _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): proximate aae of all componen,18, date ins ailed(i �own) an sour a of i formation: Were:sewage odors detected when arriving at the site(yes or ne� 6 �• Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM°LNSPECTION FORM PART.0 SYSTEM:INFORMATION.(continued) Property Address: Owner: Date of ection: a 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.); SEPTIC TANK:Z(locate on site plan) Depth below grade: Material of construction: L-�'concrete_metal_fiberglass'_polyethylene _other(explain). If tank is metal list age:— Is age.confirmed by a Certificate of Compliance (yes or no):._(attach.a'copy of certificate)Dimensions: ?,,r' x(� X Sludge depth: . Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: Distance from top of scum to top of outlet tee or baffle: Z Distance.from bottom of scum to bo om of outlet tee or baffle: How were dimensions determined:., Comments(on pumping recommendations,Tnlet and outlet tee or baffle condition,structural integrity; liquid levels s related to outlet invert, evidence of leakage, etc. 0 GREASE TRAP/('f(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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence'of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION.FORM-NOT FOR.YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property.Address: Owner: Date of pection: 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/day Alarm present(yes or no): Alarm level: Alarm in working'order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: Z (if present must be opened)(locate on site plan) Depth of liquid level above outlet inverter-.&/4'16 Comments(note if box is level and distribution to-outlets equal,any evidence of solids carryover, any evidence of akage into or of of box,e e.): ri (fit PUMP`CHAMBE)R:Alk4locate on site plan) Pumps in working order(yes or no): Alarms in working order(:yes,or ro) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued] Property Address: / Owne Date o pection: coo SOIL ABSORPTION SYSTEM(SAS): -(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 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, c.): i q (101 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 or no): Comments(note condition of soil,signs of hydraulic failure; level of ponding,.eondition of vegetation;et;}: ~•, PRIVX% (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.): 9 Page 10 of I 1 OF INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART C SYSTEM I.NFORIVIATION(continued) Property Address: 2 L)1 Owne . Date spection: Od 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. r>t7--�-- 10 Page l l of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date.of petition: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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 plan reviewed:. 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: Liar A, 11 Permijt Number: Date: Completed by:. ell HI*GH GROUND-WATER LEVEL COMPUTATION Site Location: 666 Lot N`o. Owner: T 4p/s� Address Contractor: AW7vk � Address: Notes:. ' STE.R: 1 . Measure depth to.water table. to nearest.1./10"rt.. ............. .Date montFi/da %year STEP 2 U sing.Water-Level.Range Zone and Index 1NeIl::M:a.p.-locate site anal determine: OAppro.Priate.indexwel9................ C Water-level range zone. .......... . C ............ S.a EP:.;3:: Usin g monthly.r part.' Current Water Resources Conditions" determine current-depth to water level for'indez well .......................... month/year STEP. 4. Using:Table.o.-Water;l.evel Adjustments for index well.(STEP 2A),.current depth to water Jewel for index wel.l ('STEP 3), and water-level zone (STEP•2B) determine-water-level adjustment ............. . .............................. .......... . 1,7r G7 STEP., 5 E r'.s_imate depth to:high water by subtracting th.e water-: level adjustment-(STEP 4`) from measu.red:.depth to.water level at site.(STEP 1)'................. Figure 11--,,eproducible Computation form. l4b Moo 37 . ix spa! A LLII'3 lHA ►:'g� A NDDR ` wS J e1r o -�D So Y✓»o c.T h a IA L D E R ..1R 0NNN EA COAL g S o GAZE PERMIT iSS4ED A' ,f - --- DATE C0MPLIANCE ISSUM0 �Y V\s` �Dr � d �I 4 �� S p THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....OF.... .... A p iration or R Nasal orkii Cnomitrurti�orn amit jv _14�t oon iSr o a by made f Permit to Canst ct (-Ijor Repair ( ) an Individual Sewage Disposal 1 I System at ........ .. ... ........ _.e,.,e.n - Z12,..-._- Location- r s or t No._ C ............:�°- ---� Owned Address Installe '' Address Type of Building Size Sq. feet U Dwelling—No. of Bedrooms............. ..._-----------•---___-_-_Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building No. of persons--------6_ Showers ) — Cafeteria ( ) Other fixtures ------•-•--------------------- W Design Flow.................. ........._.gallons per person pe# da�. Total daily�iow_.__._....... .�....._...._..._gal�ons�/ WSeptic Tank—Liquid capacityrW.gallons Length..,,,...&... Width..._�'_'._�..... Diameter________________ Depth..4...0_. x Disposal Trench—No..................... Width...__...F.......... Total Length......_............ Total leaching area.........._.........sq. ft. Seepage Pit No......... _ - Diameter.......... Depth below inlet......... .. Total leaching area...d/" ,*'.�7.sq. ft. Z Other Distribution box (4__ Dosing tank ( ) aPercolation Test Results Performed by.....1�-_l_L=X..... We... Date......... .. Test Pit No. I................minutes per inch Depth of Test Pit.__.____..__........ Depth to ground water---- _. 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._---._---f P'+ -•-•----•--••--•......-•-•-•......................••-----•-••---...----••-•-••-•....-••••-......-•--......................................................... Description of Soil------------•-•-•-..M.£ .1'. E.....�144-7--�....:f=1V--0---•----------------------------------------------- x U -••-•--•-•.......-•••-•....••-••.............••-•••-••---•----•••---•------•--•-••-•....-••••--•••--••....----•-••-•--••-•--•-•-----•-----•••-•-••••------•--•-•-••-•---•-••-•-•........--••-•.......... w UNature of Repairs or Alterations—Answer when applicable............................................................................................... -•------------------------------------•••---------••••••-•••••-••--•----....---•-•-•••-••-••-•-•---••---•-•--•••--------_.._....------•••-••••••------•---••---••••••••---•-••-•.........---......--•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions cVIMIE 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 h alth. Signed...... .. . ....... .... e z D`,,e Application Approved By•••••••••----•• . -• •-•......... . `�y/ /'� /---------------- Date Application Disapproved for the following reasons:----•-----------------------------------------------------------------------•-------------.........---•••-•----. .................•-•-------..........---•.....---------••-•-•-•••-••--------•-•-•....-•-•-----••••------•------------•--•--------••-•-•••••--•••••-•--•-•-•••••-•••••----------••-•----•-----•-••------- Date PermitNo......................................................... Issued....................................................... Date k No......................... Fss...f..n.._........... THE COMMONWEALTH OF MASSACHUSETTS BOAS �pplirFation for Disposal Work, (foustrurtion Frrmit Application is hereby made for a Permit to Construct (I f or Repair ( ) an Individual Sewage Disposal Syst7 at Location.A-EEd, ss 0. Owner„ Address'" Installer Address ppqq /� T -_ V Typeof Buildin g. � Size Lot... ..... .... ....Sq. feet I—I Dwelling—No. of Bedrooms............ ..................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T ype of Buildin g �Ss!'� a No. of persons------- ---------------- Showers ) — Cafeteria'IV ( ) a4 Other fixtures • ------------------ -----------------.-•••---••-•-••••---•--•-----------••-••-••......•r - W Design Flow................._. :--_. gallons per person perr day. Total dail /flow._........._ _: ............... on�j WSeptic Tank—Liquid ca.pacity/. .gallons Length../Z1._6-•-_ Width__-:-___- Diameter---------------- Depth.�3... 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- ox (4:j Dosing tank ( ) aPercolation Test Results Performed by-----R-PhF4:..._ /�✓.�'._.. Date........ .-- .. . Test Pit No. 1................minutes per inch Depth of Test Pit._.:.._._-•-----_--. Depth to ground water..... /---_.- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-__� .. ff 1 i'.! ------------------------------------------•-----....------........---........---•---------•-•-•---•-..................................................... Description of Soil................... -()-M.•-.-id..:1-1.1---7--- ...... ,#N..0------------......................................... x V -••---------•----•--.•----------------•-------•---•--•-•---....-----•-----....--•---=-.......---------••-•-------•--•---=--..........-----•----•---•----- W UNature of Repairs or Alterations—Answer when applicable._.............................................................................................. ..----•---------------------•-----------......•-----•--•-----••••-•-•-•-----•---•..........-----•--------•-••---------------•-------------•----------------•------•-•--•---•--•---•------•••--••---•---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLi, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in Signed . f ta operation untilaCertificate o Compliance has be/en issued by the boardlth. w o��GC�� 'y'.✓ 1/ !. + Date Application Approved B _,�-.... ..�.. =�.f: .�;<�-----•-•-•-••-•-•------- ----�� .� .�� ............ Date Application Disapproved for the following reasons:....... •------•--------•••--••-••••-•--•••--•••••••---••••-••--••••............... at e............- .................•-----••-----•----------........----•--••-...----••--•---...----•-----------•-•---------------•-----•----------•------•---•••--•••-•--•--•------••--------•----•......•--••-----•...•-- Date PermitNo......................................................... Issued_...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... .... ........OF..... ... :. Trrtifirafts ,af Tompliaure THIS IS TO fpERTIFY, That the Individual ,Sewage Disposal System constructed (�-) or Repairedby ( ) ------------------ ....... ----•------------------------------ ......... I taller � y�� - has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..-.._:_ _.E . i-_5.3 0---------- dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE C NSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CTION SATISFACTORY. DATE........ ? '............................................ Inspector..... .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH g ........... ...... r{r':4...OF......1 .�...��'. C Z..... FEE ................... Disposal sal Works To: , Yler:Mit ',Permission 's hereby granted._...... :- ... ...........-- _--••___.__-. to Construct ( ) or�Repair ( ) an,Individual Sewage isposal Systeem, e Street as shown on the application for Disposal Works Construction Permit NO. . .......... Dated.......................................... /l 1 IT Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON EV. A I C it G c�..T l�►•°l PLr..t� r 917C14 ALL LtdES A M!•,1 iMUt� of A t.k- Pi P)E S Tc7 .A A)p 1.-i T Hoc SY STD► 1 S H A to_ I Y �^� 2d' � �E CAST IGtb�l c� SC_ra�DL��..E AO P�/C I i "~ nl : \ �':' A,LL- 4SEPTAC Ta�akg 01- 'EIS�lTIQJ gox, A"o m �t_--- - --- A _ t -- rzEr-1oJE Au U,.1S��rA3 MATLZIA.L_ �ErJE�Tl i O ® C {`QJ O T1� !'J�EQT EI Et/AT ID.,1S OF L-EAr-V4 i-E-) PITS 4< 10 O 0 0 c) a f-C i f:-I IE W fl n'-I tS N EAf� 0 C C�i Cj �C1�'l ETtn,J 6s,�1 O P2+o2 To t�I.0 tGFi LLt y6, zc Z -- -� Ic' , / J ® \:J -c 5 oTi IE��ISE NAcoTe c?, A%~ ;, STEM Q I c r SA" TA-r- O CoreP�r.JE►.►� 5"-Lj— $E I,.►STo.��ev 1s..� h { ----TEG� f 3Do iy' O V' V �' �\ A' OJO L.L. W11-V4 TITLE ::SZ: Ot= -T-"eE STATE TYPIca,� DIST2tburl�� ©x co 0 C (0— t� lTpey c��vl= A._t, D -----_- — { ` u1NIe0 ►.eAar AP«y. ►J C-)-f' T40 SCALE T ►uarE 1�.�relt�,r,�.� tam ASV ►c,-.l, �-. Typ'rc�y�. ► .��T'k, T_ �'1S,_N_, �-+_ �1� _ P,� 3 uE,uFoetr,r� ��rT ,` T,-. A+••tee1G..J c�e��..sT ►jo�r u� scs�.lf= MOT--Tc scft 1E DB�E,C VAT/�rV P/T5 y f Gf•'_ GF Q tJA L �: Tw•.g K S t2S f►,J FOCGE D T I.a(+OuC.N o.i T t�ITld EI.Fi'TRIL vjc (Dco "let lci,-t"1•+1 OBSE�VAT/OAlS 6y: - - 2� -tIL" EMSE[>DED STtL f�s�5 ��1 S�T�:AcGE'l9 MAI�IIIOI�� TO PT,c Tr►-K N.ND !-EA!Ntw1Cti• Pt7•g Pon.r�ra,[,< BO,}4L0 QF r4C Ti/ ��� 6oiTo.�. GowrC. o6 4000 PSa- TB�T T6 t� EtVrLT lJ}' TD ..-! , R� `�"Toss Four PATiGti� ILE LGb./ F r•-1 1}N 6�?'s'i�E d,,ri7t. \ L Lcv. L y- /m 1 42 � Fl,r.rts►a gt/I.pA � IurSrt 6Q�•.. F ,Alt'S►+' r•MSN C�PPLE I }U [LER TA"tic- ovee•'d'e-cm ! LE.ACN1NG eff + 4� j= �(1 ep " T" 0,.J le INLa r * ' rN�t k= 2 .�e,.a. / 1� d 00 4s •. _ O ® .O troy D +STo.jtt n O 300' '� ecw�rCe1� CA..x. pIs-r :- --7 7?s�r. 4lo X 2 to"- �' �•-!-4 - 1 mil* �� r _ ;..'. vrr '` m 0 0 " ' ELEv L 32+a I 2� oo �x3 .. .�� .../ ��O J`t '. �E QT IL TA,ry rG 2.o '� t TV t�I('�L ���v,ACaa•✓ SY�,,T�M �cr'F 1�.L� �"- ,--.� --i 1 r V to O-T rl'2 ion AL ° Lj/�c,x ^' kw. Gv-,0 r it 7 SECTION r'4Fr'CE4, ti0T ADDRESS ----- ------- 44x Z�- LOT 47 � - ,. LEG EtVp rel DESIGN ce•TEe/� o sr -CoAlraue PROPOSED PAELLING LOCATION F.,. Jud PROPOSED SEPYAGE O/SPOSA,C SYSTEM f�E,CSo�/5 /'E.0 �y,(�OaM =�' i'Rp✓. •;odjEGE!/• I , � m«ays Ate we oze P,4, _ >, PE�aur ©T 1�/ S -,:'�. 1!�1 �_- l :►-f ._ 1 C.A/i wC ,era r A P A- F— � L6,rC t,//A/G PLO✓/DCD R PROPOSED LEACHINta pIT r r .Q.PPLICAAt'T- : E"CGt11E>=t2: `Y� p►SPps r..` �F.IJ .'f �� � ' tJiTf{IJk`7 1At2�2c�u EIyG)NELeIo� I NG- `� 100 Ex PAKI5toN �"_YZ'•�G►.il At7 .�. - i i • 1 I t = 1.1' r�' SCALE: DATE: SHEET T6-T A L_ 4 C=Pik AS NO TEU 5S\dJi�i! APPLICA.Ti 00 �,101 ,i DRAWN SY. CHKD 1{V. APPD •Y; 'LAN NO.