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HomeMy WebLinkAbout0271 WEST WIND CIRCLE - Health 271 WEST WIND CIRCLE, OSTERVILLE A= 121 011.045 J No. �v �' a Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippfication for ]Disposal *pstem Construttion permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components LoQation Address or Lot No.,.?-7 f �'� C� /_ Owner's Name,Address,and Tel.No. 61Z- Assessor's Map/Parcel 2 l 7 H C Installer�'ss Name,Address,and Tel.No.;;1o.7-�7f y ?6✓23 Designer's Name,Address,and Tel.No. 3Sd w, o Type of Building: Dwelling. No.of Bedrooms Lot Size e 7o,,,f& 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) /�Gt ��- 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 o Date 6 ,t!F Application Approved by Date Application Disapproved by Date for the following reasons Permit No.-C1n i Date Issued .r. `� • - ._.. R 7'.,.._.y ,r.....1. -.„ i�.. ,_ p,,:..,..,.,w;... ,.+A..:mac,"�.'� :.. -.n.,ry�• yNO. Fee THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer:./ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(Seupgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.,�'7 ee—,,ra!G/ 07er's Name,Address,and Tel.No. ('/T—��3~6� Assessor's Map/Parcel Installer's Name,Address,and Tel. ?d7Z-F" Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms �`' Lot Size 76",,iL_ 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 y Nature of Repairs or Altercations(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 hag been issued by this Board of Health. / Signed _. _ Date Application Approved by_` 1 Yli1 C,IJ,4. -X Q� Date Application Disapproved by Date for the following reasons " - Permit No. ( -- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO C,,ERRTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓) Upgraded( ) Abandoned( )by C. S'.•r�,`��5 at T^;'r, has been constructed in accordance - - - - --with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer �� .�..� Designer #bedrooms Approved design flow----- and The issuance of this pen!nitJshall not be construed as a guarantee that the system func on as de is wed. Date ���((/// Inspectors No ( �" / / a Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS �isosaY 6pstem Construction permit Permission is hereby granted to Construct( ) Repair(G o< Upgrade( ) �Abandon( ) System located at T/ 3 C.e.,�"-./ /'� ✓_ // (( 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. r Provided:Construction must be completed within three years of the date of this permit. Date ' / CL� I ` Approved by Y ePf � r AsBuilt Page 1 of 1 1 G 1 110 TOWN OF BARNSTABLE f LON e m(,1 _ r���EWAGE# - VILLAGE yS �L� ASSESSOR'S MAP&LOT,!JZ UY- Dom' MtTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERmrrDATE: COMPLIANCE DATE: Separation Distance Between the: Q� G Maximum Adjusted Groundwater Table and Bottom of Leaching ractli 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 ` 40 90 o q 48 4 L B AC H1 A8 C C4 3°c B+D Lp CA cc Iq co �q http://issgl2/intranet/propdata/prebuilt.aspx?mappar=121011045&seq=1 6/6/2018 Town,of Barnstable Barnstable A Amer� Cfty Regulatory Services Department RARNSTAHLE. �6; Public Health Division Alf°"AP�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1520 0000 1967 7467 May 29, 2018 DIMINICO, ROBERT & JOAN 401 FISHER ST WALPOLE, MA 02081 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 271 West-wind Circle, Osterville, MA was inspected on 04/28/2018 by John Graci, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Distribution box needs to be replaced. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health- . . Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\271 Westwind Circle Osterville.doc �try tom, 1 Town of Barnstable • r BAftNSTABLL Regulatory Services Department Alfp MA'S A Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts �a f _ al/ _0#S W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'GSM 271 WESTWIND CIRCLE i Property Address d ROBERT DIMINICO Owner Owner's Name information is OSTERVILI,,E/BARNSTABLE MA 02540 4/28/2018 , required for every page. City/Town State Zip Code Date of Inspection j„• 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 filling out forms $ 13 03 S on the computer, use only the tab 1. Inspector: key to move your cursor-do not JOHN GRACI use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS, LLC Company Name PO BOX 2119 Company Address TEATICKET MA 02536 City/Town State Zip Code 508-641-6694 S 1468 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by th Local Approving Authority 04/28/2018 Inspector's Signature Date The system inspector shall subm copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd r greater, the inspector and the system owner shall submit the report to the appropriate regiona office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if plicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: NA B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): NA t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): THE DISTRIBUTION BOX NEEDS TO BE REPLACED ❑ 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): NA C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water Supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: NA D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts _ Form W Title 5 Official Inspection o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 - page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 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 i regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 _ Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ND t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK DISTRIBUTION BOX AND 1000 GALLON LEACH PIT Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No 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 d TOWN 9 ( Y 9 (gP ))� Detail: 2017- 4000 2016 40,000 ' Sump pump? ❑ Yes ® No Last date of occupancy: D eCUPIED Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NAGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: NA t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA 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): NA t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 07/17/1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: GREATER THAN 10+ FEET feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO COMMENT Septic Tank (locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: NA years I Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 G Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? MEASURED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION . RECOMMEND PUMPING EVERY 2-3 YEARS DEPENDING ON USAGE. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 o`17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA ' 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee-or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments (condition of alarm and float switches, etc.): NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVIL LE/BAR NSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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 NEEDS TO BE REPLACED. 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.): NA * 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: NA t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000G ❑ leaching chambers number: NA ❑ leaching galleries number: NA ❑ leaching trenches number, length: NA ❑ leaching fields number, dimensions: NA ❑ overflow cesspool number: NA ❑ innovative/alternative system Type/name of technology: NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-1000 GALLON LEACH PIT WAS EMPTY AT TIME OF INSPECTION. STAIN LINE INDICATED NEVER MORE THAN 2' LEACH PIT APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth —top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA Privy (locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts M. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is re E/BARNSTABLE d for OSTERVILL MA 02540 4/28/2018. _ require � _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within.100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately O O bO G. SIT- o O a 00 I�=riG LF A 6 C 1-43.4 . 1-19.9 1-26.6 246 2-24.7 2-29:40. 3-49.3 3-30 3_34 4-71:3 4-47.6 4-29.6 15ins•3/13 Title 5'Official lns ection Form:Subsurface Sewage Disposal P 9 System:•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: . GREATER THAN 12+ FEET feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 271 WESTWIND CIRCLE Property Address ROBERT DIMINICO Owner Owner's Name information is required for every OSTERVILLE/BARNSTABLE MA 02540 4/28/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION m A TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner's Name: JOAN DIMINICO Owner's Address: 401 FISHER STREET,WALPOLE,MA.02081 Date of Inspection: 7/30/01 Name of Inspector: (please print) JOHN GRACI RECEIVED Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 AUG 0 7 2001 Telephone Numbee,-508-564-6813 FAX 508-564-7270 TOWN OF BARNSTABLE HEALTH DEPT. 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 pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: Date: 7/30/01 The system inspector shall submi 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 SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM. RECOMMEND RAISING COVERS AND RECOMMEND MOVING SPRINKLER LINE FROM AREA OF PIT. ****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. Titlr 5 ►nc irrtinn Form A!I 500(10 I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ;""'CERTIFICATION (continued) Property Address: 271 WESTWIND CIRCLE OSTERVILLE, MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 Inspection Summary: Check A,B,C,D or E/,ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM. RECOMMEND RAISING COVERS AND RECOMMEND MOVING SPRINKLER LINE FROM AREA OF PIT. 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,NI))in the for the following statements.If"not determined"please explain. n/a 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 old1s available. ND explain: n/a n/a Observation of sewage backup'or break`ut or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or'uneveii distribution box. System will pass inspection if(with approval of Board of Health): a,. a' _ broken pipe(s)are replaced _ obstruction is removed r _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than.4times 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: n/a tx ?7: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 'F `CERTIFICATION(continued) Property Address: 271 WESTWIND.CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 C. Further Evaluation is Required by the Board of Health: j _ 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 31.0 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 c'- a 3 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''wate'r 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 at4SAS and the SAS is within 50 feet of a private water supply well.. _ The system has a septic tank and SA%S and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "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: n/a sk . a` . Z Page 4 of 11 ; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 ' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No _ X Backup of sewage into facility or•system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or•surface waters due to an overloaded or clogged SAS or cesspool ' X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy-is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy'•is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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.] (Yes/No)The system fails. I have.determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system,fails.'The system owner should contact the Board of Health to determine what will be necessary to correct the failure. " E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of.a surface drinking water supply _ X the system is within 200 feet of a,tributary to a surface drinking water supply •i r 1:. X 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 n 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. !t� d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back,up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems`? ` t The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example,'a plan at the Board of Health. X _ 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)] K S Pagc 6 of I I OFFICIAL INSPECTIONYORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate.inspection required] Laundry system inspected(yes or no): NO - Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1997 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,ventirig,,eyidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or.baffle:32" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural"integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE MAIN SEPTIC TANK ANDIALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYST,EM'S USEFULL LIFE GREASE TRAP: _(locate on site plan) ' Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a . t 7 Page 8 of I 1 # �' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE iSEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity:-n/a gallons s Design Flow: n/a gallons/day Alarm present(yes or no): N/A z Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a " Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present-•must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): {; DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND AND ALSO APPEARS TO BE FUNCTIONING PROPERLY. PUMP CHAMBER:_(locate on site plan) f Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,.condition of pumps and appurtenances,etc.): n/a .1 Y r i ' R 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: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system .Type/name of technology: n/a Comments(note condition of soil,signs of'hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY.THERE IS 2 FEET OF LEACHING CAPACITY LEFT. RECOMMEND RAISING COVER.RECOMMEND MOVING SPRINKLER LINE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) ' Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a PRIVY: (locate on site plan) { Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a i Q Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 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. 6 A . C 6e g L.rt_� 3 4 c Kj 3 go u7 cc 3q 6 I Page I I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 271 WESTWIND CIRCLE OSTERVILLE,MA 02655 Owner: JOAN DIMINICO Date of Inspection: 7/30/01 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 1,50 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12 FEET _ C0\1\ION3VEALTH OF D,LkSSACHUSETTS EXECUTIVEOFFICE OF ENVIRONMENTAL AFFAIRS,. �= DEPARTMENT OF 'ENVIRONMENTAL PROTECTI 2V r: •i:i0u ONERINTER STREET. BOSTON 1L4 02106 (617) 292` O OCT 2 8 §RUDY O\ 1 99 Secbe: r, TOWW�� D o ARGEO PAUL CELLUCCI 4 �' Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Q CERTIFICATION ` Na )a �1�.. me of Owner Property Address: A� W� W k (jg\'C1L.V l�l%4 Address of Owner: Date of Inspection:. 'k 0` Name of Inspector:(Please Print) 1 C!r / `1 I am a DEP approved system inspector pursuant to Section 15.340 of Trde 5(310 CMR 15,0001 Company Name: AZ'1:. Ar? o1�4-c1 Mang Address: Telephone Number: / Sow ) /L- • e_o CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true; accurate y training and experience in the proper function and and complete as of the time of inspection. The inspection was performed based on m maintenance of on-site sewage disposal systems. The system. h Passes , _ Conditionally Passes , LLNeedds rther Evaluati a Local Approving Authority Date: V Inspectors Signawr The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board ofHalthe th r Dspe)wi hind the n thirty(301 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd o greater, shall submit the report to the appropriate regional offisystem ownef. ce 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: NOTES AND COMMENTS o v revised 9/2/98 Page IofII M• ' ' 2 C. Panted on Recycled Piper it SUBS URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r , . PART A CERTIFICATION (continued) cs +ropert al i ti y.Address: Jwner: Date of Inspection: P�� INSPECTION SUMMARY:-� Check A, B, C, or D: A. SYSTEM PASSES: -1k I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y. N. or 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 complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced " _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass Inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 z;::fA ,page=oril III a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: - Conditions exist which require further evaluation by the Board of Health in order to deter ine if the system is failin;to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE TH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland r a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PU IC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption sy tem(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ` . _ The system has a septic tank and soil absorption ystem and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorptio system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorpti system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water nalysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility a d the is of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine dis nce (approximation not valid). 3) OTHER ,.i 'revised 9/2/98 Page3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described it 10 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine hat will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due to an overloaded clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface aters due town overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to a overloadea or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or available lume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or pri is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I o a public well. Any portion of a cesspool or privy is within 50 feet f a private water supply well. Any portion of a cesspool or privy is less-than 1 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well h s been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds, mmonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the folio mg: The following criteria apply to large systems in ad ition to the criteria above: The system serves a facility with a design flow f 10.000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment becaus 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 f a tributary to a surface drinking water supply the system is located In a n' rogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system hall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infor tion. revised 9/2/98 Page 4of11 ' e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST e'ro Address: PertY 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 nermal 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. w _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. ` _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if(any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [I5.302(3)(b)1 ; The facility owner(and occupants,if different from owner)were provided with information on the propermaintenaano-of SubSurface Disposal Systems. a revised 9/2/98 Pagr• oru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK' PART C 11 t J SYSTEM INFORMATION 'roperty Address: a� l 1XSTL1NJ Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (desi n):(—%-"*% Number of bedrooms (actual):02 Total DESIGN flow. Number of current residents: Garbage grinder(yes or no): Laundry(separate system)__(yes or no): 0; If yes, separate inspection required Laundry system inspected (Yes or no) Seasonal use (yes or not: S Y b� Water meter readings, if available (last two year's usage (gpd): Sump Pump(yes or no): Last date of occupancy: N\ COMMERCIALIINDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Lost date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECQWSand sourc of i;cf�prmamon: System)Pumped Is part of inspectioh: (yes or no)%tL If yes, volume pumped: gallons Reason for pumping: F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other `G1 � APPROXIMATE AGE of all components, date installed fif known)and source of information: �11�%NC Sewage odors detected when arriving at the site: (yes or no)Ito revised 9/2/98 Page 6(if ll ' 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 PART C SYSTEM INFORMATION(continued) �l c 'roperty Address: 1 � Owner: Date of Inspection: BUILDING SEWER: 4 _ (Locate on site plan) Depth below grade:a Material of construction:_cast iron x40 PVC_other (explain) Distance from private water supply well or suction line ' Diameter �l1 Comments: (conditi n of joints, ven ing, evidence of lea am t SEPTIC TANK: (locate on site pla ) Depth below grade:-0� Material of construction: l�concrete_metal_Fiberglass _Polyethylene_other explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: t( T Distance from top of sludge to bottom of outlet tee or baffle:-1�2, t( %lL Scum thickness:_ , Distance from top of scum to top of outlet tee or baffle:_ ` 14 Distance from bottom of scum to bottom of outlet tee or affie: How dimensions were determined. v ;omments: (recommendation for pumping, condition of'nI and outl t tees or (fles, depth of liquid levelin relation to outlet i vent, structu al tegrity, *deuce o akage etc.) kvb W � 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 9/2/98 Page 7ortl ' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwedl Iroperty Address:a.� ST, Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: S (locate on site plan) Depth of liquid level above outlet invert '� _. Comments: - (note if I veI and di tribution is qua! evi nce of solid s Carr oUrvid of lea a e into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,•condition of pumps and appurtenances,etc.) revised 9/2/98 Page of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C t ', �C SYSTEM INFORMATION (continued) 4 Address: �openy a� ` W`�� wN� - Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible; excav ion not required, location may be approximated by.non-intrusive methods) If not located, explain: Type: leaching pits, numberl& leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: r In to condition of$oi1Q signs of Wraulic failure, level of onding, amp soi, on i 'on of vegetation, tc.) l�'l _ (� r t l— dl Iv �I.C�� or- CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: 9epth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of$oil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Dimensions: Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'rop"Address: Jwrw: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landm arks or benchmarks supply locate all wells within 100' (Locate where public water pp Y comes into house) V3— ab revised 9/2/98 page ioorti ` L G •SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM',r PART C FSYSTEM INFORMATION.(coritinued) Address: r operty - , Owner: Date of Inspection: NRCS Report name tZ - — —"— Soil Type_ Typical depth to groundwater_ USGS Date website visited ND Observation Wells checked a Groundwater depth: Shallow Moderate Deep SITE EXAM Slope 614cVv. Surface water If" • Check Cellar Shallow wells Estimated Depth to Groundwater Feet i Please indicate all the methods used to determine High Groundwater Elevation: F , Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.)'..,, Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records k- e _Checked local excavators, installers ' Used USGS Data Describe how you e9labli ed a High Groundwater Elevation. (Must be completed) e „ r v S �.eolGt".s l CIA) b [y n revised 9/2/98 Page 11of11 ^ 1,07- 34 T, o Z-,ar .3. Fx i ST ► T Vat ,D P-,px i' �^► S.EtiT7Cr'Tk+VIG, \ 1 O o LAX(.ST, v+v t ( 1 t /z5 c � 600otltta- got 33d0 `sCA4..ic ' L0C . f10X f7l SEWAGE 1''ER..MIT ' VILLAGE INST A LLER'S 11MA A A ADDRESS so" T60 so 3 U I L 0 E R Opt OWHEN U' fArmPr-olly71�5 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED o Opt O TAB gl y� Lo y + ' ` TOWN OF BARNSTABLE A.r LOC ION ( IA�eS'I l�L nCJ CC(C,�EWAGE # VILLAGE � � ASSESSOR'S MAP & LOTL� ate. 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: mZea�c Feet Maumum Adjusted Groundwater Table and Botto 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 40 '46 u L 6 Ac AD �� a � a Bo Lp „: 1C.."NN tJ I S N'yC"' . SEWAGE # `Jf!_L?.L,F_ t Y >� ��. ASSESSC,R'S i.A-P r?i 1roT l2 �0�- 13sd,ST:LL.ER'S 14A-ME&PHONE NO._ — SEP"1 AC TA?:K CAPACITY . i600!2[fir k&a l -- -- LEACHDiG FAC U I? .: (type) (size) -- NI)-OF BEDROOMS 3 4 1 T nAT>r:.- - ----oo1 LiAN_ DATE: -- Separador,Distance Between-the: Pyla cimum Adiusted Gro;m w tter Tab( ' ' :T �! .IZ^,-i4 Fcct Private Water Supply Weil Lnd Leaching Facility (U any wells czist f on site or within 200?fete,of leaching faciEty) —,' Fe f E,�ge`of Wetland and Leacljng Facility (If any wetlands e:,;st wit!- n'300 fect cf leaching facility) tFe-' Pt Ila L 0 C : Tl0 -70farI/ SEVYAGE PERM! T WO. VILLAGE _ 65ferv( 1 "MS7ALLEA'S MYNA A A '0DRESS 8UILDER OR OWNER -_ At, & 9 A T E PERMIT ISSUED Z6S- DAT E G 0 M P L i A N C E , 5 S U ED V� � { , •� �� �o'� . 0 �,� � t � I. '���� c . �� .� �y r 1..�� �� i' No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Works Tnnstrnrtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .....• 7....--- ...... — ---- 4.0........ Locat' ddr s ..........G.. 1 .. .. i� -ram -t. . � dress a -------------------ki. .-- � c�lft _(�� '- ............---_--I----Y...�. r�J�.���• -........... Installer Address U Type of Building Size Lot.../J ,6 fjj.-Sq. feet a Dwelling—No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ,�� No. of persons Showers ( Cafeteria Q' Other fixtures ) ( ) < ------------------------- ----------------------------------------------------------------------•-------------------- w Design Flow................ ... ...._.._._._._gallons per person p7r d�. Total daily�ow..........3.,3,0...............gall,6ns. 94 Septic Tank—Liquid'capacity/-�.�,o.gallons Length_0.� Width.__...___ Diameter................ Depth... Disposal Trench—No. .................... Width....... ----------- Total Length................ Total leaching area....................sq. ft. Seepage Pit No________ __________ Diameter--------j�....... Depth below inlet....._......_... Total leaching area. ., _.17sq. ft. Z Other Distribution box ( () Dosing tank ( ) 1­4 4 Percolation Test Results Performed by..... - _ _> 1?'� t� �, � Date.......V*' -:.�-/- 04 Test Pit No. 1................minutes per inch Depth of Test Pit----- _,,rr... Depth to ground water (s, Test Pit No. 2................minutes per inch Depth of Test Pit......<���----- Depth to ground water.. 0 -------------- ---------...........------------.... O. Description of Soil------------------------ ...'��.......... ---� �alew----- c, w U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------------------------------------------------------•------........--------------------------•-----....----------------------------------------------------•--•-------• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed. .......................... Date Application Approved By....................................... --------1 .=_. �. ...--------•--••--------------•-- ----..... =gi p ` Date Application Disapproved for the following reasons---------------------------------------------------------------------------•----------------------------------• ......-•--•-----•---•--------------------------------------••----•--------•-----••--------••----------•----....----------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued-....................................................... Date CFims.......................... • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL T I Appliration for lliipusal Worko Tottatrurtion Vrrmit f Application is hereby made for a Permit to Construct .(�) or Repair ( ) an Individual Sewage Disposal System at: t................. .....................1-1,V-12..... — 1 _E ,_'° ..._ ..�. Loca on-Addr s o Lot NID ,- •-- •. / t / . 1 ... W �.��` I2.. / �%!� 7 t�/ �%f / /7 t-4 Iddre�s� ••• --- _.. .:.... -•-•--.-•-- '.. f........................ Installer Address U ,w Type of Building Size Lot.- ::C-61t f Sq. feet 1•-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building No. of persons......... _----____---_ Showers (0) — Cafeteria ( ) dOther fixtures ------------------------------•---------------------------------------------------------•--------•------- Design Flow...............t" ._ gallons per person pgr d�a� Total daily flow..._......_ t gallons. W .�r W Septic Tank—Liquic�ca.pacity 47,,4,9.g llons Length.1 ., .:. Width._. ....... Diameter................ Depth...t.1 a r Disposal Trench—No..................... Width....... Total Length Total leaching area..__.............._.s ft. x p----------- g g q• Seepage Pit No--------/.......... Diameter........ .......... Depth below inlet....... ......... Total leaching area ja.p9_-7..sq. ft. z Other Distribution box O Doing tank ( ) a Percolation Test Results Performed b ._...r� _- _ �?.t,.�_ZZYX Date...... _ � -__ �/1 y f . y -____ Test Pit No. 1................minutes per inch Depth of Test Pit.....r..4.......... Depth to ground water-----<................... (=1 Test Pit No. 2................minutes per inch Depth of Test,Pit... ...... Depth to ground watetMIV E5,4� ----••------------- :_.... Description of Soil :. :. J. ` ?` !� ....... . j ... x c, ----- 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. r Signed. ✓ ;-�---� .. ,.-ti:--------•- -b-�--^�-�-:�.-=.tea f} Date Application Approved By....................................` !'�-- .e. ...........---------------••--- ----- / a ✓ ----- Date Application Disapproved for the following reasons:---•----------------••-----•--•-•----------------------••-•-------------------••----------------------...._.. --•-••••..........-••---•----•-••-•--•••--•-•---.......••-••-•--•-•-•-•-•....••--•---....--••••--.........-••---••----••--•--••-•---•----••--•--•••------••-••-----••-•-•••••••••----•-••----•--•-•--•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD . OF HEALTH Trrtif irate of Toutphaurrr� THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installer r at. - f /�� =; j it '— � s L .�_. a : t� has been install�il m accordance with the provisions of TITIE 5 o C he State Sanitary Code as described in the application for Disposal Works Construction Permit No...._..._..-. ........................ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUN9TION SATISFACTORY. DATE.................... ... ................................... Inspector......... --• ... .................................................. .., / THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �fZX C.: !"a✓� OF.. No......................... FEE... .............. i �ro �t1 urk �unrUan rruti Permission s herebygranted �r%�:.. ----- to Construct (- ) or%Repair ( ) an Individual Sewage Disposal System ' !V P.lvV-g re et as shown on the application for Disposal Works Construction Permit No..................... Dated...................................... _---•--.................. --- .•- --------------------------- .------------ ` .............. ....._ i, DATE.. Board of Health [ .._/�z .�V------------ FORM 1255 A. M. SULKIN, INC., BOSTON 1 KL.ev- I `:,LEI• (`I_--AJ-L ELE-Ai `3W-.-,ti A" mep. ! SEA LE'eEL. T-L: F 4 ---- - - ---- -i es+•se D elo+ �A 5 C fir,C CiIAT uw� (� - Ptl--W ALL LsdES A Ntll1',MUr`1 of --• I ` 4 UN LE�� I�TNE�.-1 t5 E S.P°EG>F 1 E D. AL.L_ PIPES To AAITJ I.d TEE �v5rE-�-"; •_>Ha��_ /"� DE CAST I>2r�►J � SC"aE DL>:_-E AO F' nLei lS/ r (1 t — ALL SEPr< TAJJK5 L.E0".Gr-1,'JG-, Ptrt SHa�t LE vE��S.�Ec� ti� /� Q �, %4 - 2-0 v ►FEEL �a�.:,,.J.�S WHEN INS7ALl EPUNDER PAVlfvv .N , �Y ��j -� - -- -� `" `" &-- ftE[`1C✓E Au- U�JSv S-A3LE MATtiZIAL 8F_�1E�TL1 �0� � (� T-"C t"�/E ler E LE VAT,O�.1 S OF L E AC F�� �� P i 15 Ft� c { �.J � U �i �i U AN� © L _ _ r ' n A �u0S Of 10 AiJ0 EpnC.bLFiLL- \cJtTN C"z- i C L-11 t r I t ` U �� ` v �T44E dAR/�IS T/ 6LC E� �� OF t11�1=1�1 MUST _ 1 SA.J�r^ I rl �s Q CONepw'JIJEIJ�S 'S1IAL�_Gy aE stilST A��cC� IvJ r { TEc i Z t L IRCGG>�Dt+.l�_� W 1Zl a T�TL E _ of T�♦� a>TATE -TYPICAL DI ST�16U7-10�1 ©JL 1 0 co O =', 0 -- -- t4jN1Gr4 Ne," a4L] P���/. ►J O� TcA §c ALE '-. -J- `-"—.-- -' � kl oTE %"t;k l 000 <5k r Typ lc A>� t o00 �A�. G. ,��'� .�„���PAS!•±�Z�_- �'�� - _ate- O0,69 VAT/0it! 0/T5 >0E►.,FC�P1�D ��Pt > —"x Sy ► CPT -9n) SCE LE ►bT Te �CI.�E Qw- eQuAt- Liam. T^J'4kcs Q`c qJ FOGGED T, OUG,•t G.fT - ",eCOLAr/40A/ Ap-ATZ- ELF,CTRwL ,dj4e�- Eo vr,ke w,TN e�V•tT/oA15 6 SDNN TAC2t MOTC:pcc'��`� �`n�+.r^--W -�•� EMQEOOE� St>�4 fc'.Ofl"S '' S�PTtC TI►t-J�C /04 P LSh�►1�AIC,.- PtSg 093 y TaR 6oTCowI. COLIC. /6 4000 r-%a. 'T>;sST To SSE DV�LT UP TO ENGIto,1c4~R: A 40W E G+NEfRa�4 , It��, e.ELLVL! Frw.ts}N e`rs�-'� �Qf-' FOVwI ATjow� 72 CJ cJE ( i:14V... _ FrrJ,15►k 69A F sA!►SH 6-QA�.L7E F sA/154 E.6CI► DE Gva�. �FrtLS}I Cyfi►pE• 4 1 a E e T+++t sc CJNE� [�'E�cx LEA C LA N G wT• r d g" Gse'�STc.-Je �AIWLGT r 00 syr 4 FOCGe fl fA►1G. IM1/ �(otS�T �o>< ,• •• Q ® .0 ' •,- ¢uy�v gTGa1C K�Q9C iba►�. o0 - f cJE�'tL TAIJIL • sLLl6L.� SrAVLE TVP 1 C-A L 5 E W^C7C S15TE!�{ P2�7r F t is 7 ^5 fT iJi` /~ !- t '7 _'� �t� •-� nloT TnSC.�►.L_6 LE/RCNInl(n p IFx 15T f 31y •'� � x sST 1 MAP SECTION PARCEL LOT ADDRESS' LCX I S T, NicATtoo)-lftl �?I � 1GI-U W l E 4-1 ,GEs Nv - ` - PROPOSED PI Y&UNG L OCA T ION /N 4f �� � NfJF;k.,1T PROPOSED SEdMAGE DISPOSAL, SYSTEM / �` _ v�i[sows oe •rr Pr. �j T 'Il i^b' p JT 4C Y 4f,6whV6 le-fail rmp freVlA!!LD PraDPiss s p L�AGH t�tQ! P! 1' / ; lGRtT ii~1►eG t U o�rQ: r ') b o�SPt�Ss•l.. �'1 ►009/® ExPAW510nl ��� y: G,pG'. FkLMcOTH HI>aNv/^y o? ROBE M,FA.s..1�a Ot MA( . 5�: flES�G r•1 ti. ` INC- p /�� / 026 RAYMOND �Al� (Jd✓Pit Z 2 x 'Y t a X(. +C S , Na 19875 $�D�N�c t. ��e�a wq sE glw'1"ICr SHEET l30-s-:4 As AK FA X y`x 1. 5^ ' ��/scIC A,5 NOTED --&NEE /l, /ge-4 > 4F 1 �EV1rc1� ��1C.�'t l Ot•.� �� J���.i roT�� �z , t,E ":; �, -, D*^LAIN my; C#Wz sy. APP'O sy: PLAN ► a