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HomeMy WebLinkAbout0095 WINDSWEPT WAY - Health ( 95 WINDSWEPT WAY, OSTERVILLE �I Commonwealth of Massachusetts osa -owl ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name / information is required for every Osterville MA 02655 3/11/20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information cS/ Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails i 3/11/20 Inspe Signa ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insP.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage,Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way, Property Address Krant Owner Owners Name information is required for every Osterville MA 02655 3/11/20 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2612 0 1 8 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as.described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ E 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)] I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �e 95 Windswept Way Property Address Krant Owner Owners Name information is required for every Osterville MA 02655 3/11/20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: No engineered plan or permit on file at BOH, system is typical of 4 bedroom Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 219 GPD 9 ( Y 9 (9P ))� Detail 2018 84,000 gallons used, 2019 76,000 gallons used Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No �j Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped annually per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy p ❑ Shared system (yes or no) (if yes, attach previous. inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1985 per age of the home Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC ❑,other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c� Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form 5FSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 55v� 95 Windswept Way Property Address Krant Owner Owners Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace-1/2" >2,1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >2" 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Cisterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 . 3/11/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cost.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm,and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0i, 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.): D-box is 2' below grade, average condition for its age t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): f * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit"C"as depicted on pg.16 is 4' below grade, cover raised to 18"of grade, effluent level is 2' below the invert, no indication of past hydraulic failure, Pit"D"as depicted is 2' below grade, effluent level is 2' below the invert, no indication of past hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of pondirig, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 13. Privylocate on site plan): ( P ) Materials of construction: Dimensions Depth of solids -Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r I� c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Cr z y 0 O 3a 3 ° 3 57 33 C �g C_ 4 t5insp.doc-rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner's Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >12'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: n/a Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: No records found ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the sit to be at 20'msl and nearby surface water at 2' msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 95 Windswept Way Property Address Krant Owner Owner s Name information is required for every Osterville MA 02655 3/11/20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked k ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg_ 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 DATE: 6/9/9�9 PROPERTY ADDRESS: ----------------------- 95 Windswept Waj________ Osterville, Ma. ------------------------ On the above date, I Inspected the septic system at the above address. I This system consists of the following: r 1 . 1 -1500 gallon septic tank 2. 2-1000 gallon leaching pits 3. 1 - Distribution Box Based on my Inspection, I certify the following conditions: 01 � a 4. This is a title five septic system ( 78 code) 5 . The septic system- is in proper working order at the present time. 6. Tank cover is 13" below grade . Pit ones cover is 30" below grade . Pit 2 is 48" below grade . Box cover 18" below grade. SIGNATURE:1 Name:_,�z ` Company: Jose_ph_P. Macomber_& Son , Inc . Address: Box 66 Centerville , Ma . 02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY WAY• �8 -I . JOSEPH P. MACOMBER & SON, INC. �y Tanks-Cesspools-Leachflelds VE6 Pumped & Installed tp( Town Sewer Connections —p ��t, 3 1999 P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 s, FO*Nor �s E �' C- COMMONWEALTH OF MASSACHTJSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 7RL DY COX Secreca. ARGEO PAUL CELLUCCI DAVID B. STRi:!! Governor Co:rrss:c SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Property Address: 95 Windswept Way Nam. ofOwne.Jean Ferrone Osterville Address or owner:BQx,� _. oat& or Inspection: Osterville, Ma. 02655 Name of Inspector:tP(adsb Ptt1 Joseph P. Macomber Jr.. 1 am a DEP approved system inspector pur&u"to Section 15.340 of rile 5 (310 CMR 15.000) corspanyHarrw: Joseph P. Macomber & Son, Inc. 6A-Lw Address: Box 66, Centervi 1 1 P., Ma 02632-0066 T er api,orb Nurnber:5 0 A-77 5-R 1 3 A CERTIFICATION STATEMENT 1 certify that I have personally Inspected the &*wage disposal system at We address and that the Information reported below is true, eccUrate and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper runcuon and maintenance of on-si �te &&#wage disposal systems. The system: Y Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails inspector's Signature: / Date: �4 The System Inspect shell submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)wtthin shiny (30) days o! 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 Mali submit the report to the appropriate regional office of the Department of•Envkonmerual Protection. The original should be sent totru system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1of11 �� Vroled on Rscyclsd P,pa, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(corrtinued) P►opeetyAddress: 95 Windswept WaY, Osterville OwOBI: Jean Ferrone Data of Inspection: 6/9/9 9 INSPECTION SUMMARY: check A, B, C, of D: A. SYSTEM PASSES: �1 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: Pit cnvPrG chniil ri he >rai Qed Pit 93 IS 39" h236iJ B. SYSTEM CONDITIONALLY PASSES: 4& 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. AIV 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 la levelled or replaced " The system required pumpirig•more than-fourtimes a yeardue to broken or obstructed pipe(s). The system wHtjmw-^ inspection if(with approval of the Board of Health)- - broken pipe(s) are replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION (corrdnuod) PtotY"—: 95 Windswept Way, Osterville Owr"r Jean Ferrone D,su of 4tisprcdors: 6/9/9 9 _ C. FURTHER EVALUATION LS REQUIRED BY THE BOARD OF HEALTH: Condldons exist which require further evaluation by-the Board of Health In order to determine If the system Is falling to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CUR 16.3-03 (t)(b) THAT THE SYS tS NOT RJNCTIONWO W A!MANNER WtUCHWILLPROTECT THE PUBUC kiEALTFIANO SAFETY BIND THE EJlL80N`)4ETCT: .(.� Cesspool or privy Is within 60 fset of surface water Cesspool or privy Is wlthln 60 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FALL UNLESS THE BOARD OF HEALTH(AND PUBUC WATER SUPPLIER. V ANY)DETER1.WES THAT THE SYSM FUNCTIONWG W A kUU1NER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ETlVLRONIAENT: The system has a &optic tank and soil absorption system(SAS) and the SAS Is within 100 test of a &urtace water supptY uib"ry to a surface water supply, The system has a septic tank and&oil absorption system and the SAS Is wlthln a Zone I of a public water supply well. The system has a septic tank and &oil &bsorption system and the SAS Is within 60 feet of a private water supply wsu. The system has a&optic tank and &oil absorption system and the SAS Is Is&& than 100 feet but 60 test or more from e prlv&ts water supply well,unless a well water an&lysls for collform bacteria and volatile organic compounds indicates tru well is free from pollution from that facility and the prose ce of ammonla nitrogen and Nuats Nuogen Is &Quaj to or Ifs, than 6 ppm. Method used to determine distance (approximadon not valid).- 3) OTHER Ad revised 9/2/98 Page 3of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropemAddra": 95 Windswept Way, osterville Owner: Jean Ferrone Data of Inspection: 6/9/9 9 D. SYSTEM FAILS: You must indicate either "Yes" or 'No' to each of the following:. vri I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No / �/ Backup of•sevdege irrtoiaciNty-orwTstem component-due tto an overloadedle orcgged-SAS•or•casspool. 41 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 dis lbutio ox above outlet invert due to an overloaded or clogged SAS or cesspool. • less Liquid depth in�iss less than 6' below Invert or available volume is lass than 1/2.day How. Required pumping more than 4 times In the.last year NOT due to clogged or obstructed pipe(s), Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or 'No' to each of the following: The following criteria apply to large systems In addition to the criteria above: AlL The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yea No �/� the system is within 400 feet of a surface drinking water supply 1W JJ. the system•is-within 200 feetof-a-tribut a ary-to suFfaoo-dFkJv;rag-water-supply - --- AJI the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15,304(2). Please consult the local regional office of the Department for further information. revised 9 2 98 Page 4orII ! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART B CHECKLIST PropertyAddre": 95 Windswept ,Way, Osterville owner: Jean Ferrone Data of kupection: 6/9/9 9 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. -4 -None of the systemcompoaanU.hauabaon pumped4orzat,Jeasttwoaweaka anrtthe'system -z hash"aeceiaiw w gs.u!flow TT rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this Inspection. As built plans have been obtained and examined. Note If they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected f�orr��signs of breakout. All system components,'4XCIuding the Soil Absorption System, have bean located on the site. _ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inspected for condition of baffle! or toes, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe 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) 115.302(3)(b)) The facility owner.(and.nt upants�Jt difiaraW frov>.oxcnarl.vicere prc�icied.wiih ininrmaiioaan Th y maint � aa��s n Subsurface Disposal Systems. ' revised 9/2/98 Page 5of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ProvotyAddre": 95 Windswept Way, Osterville Owner: Jean Ferrone Date of Inspection: 6/9/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: L1-b g.p.d./bedro Number of bedrooms( si ): Number of bedrooms(actual):_ Total DESIGN flow , Number of current residents: Garbage grinder(yes or no):� Laundry(separate system) ( s or _;: If yes, sepaWalnspacdon.required Laundry system Inspected a or no) O j� _ Seasonal use(yes or no):_ Water meter readings,if ova able (last two year's usage(gpd): ;o7f' 30 Sump Pump(yes or no): Last date of occupancy: COMMERCIAI ANDUSTRIAL: Type of establishment: Design flow: d Based on 16.203) Basis of design flow Grease trap present: (yes or no) ee,, Industrial Waste Holding Tank present:(yes or no) Non sanitary waste discharged to the Tide 5 stem: (yes or no!/� Water meter readings,it avajlable: /� _ Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of in action:(yes or no) If yes,volume pumped: gallons Reason for pumping: If TYPE OF YSTEM 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) 1/A Technology etc. Attach copy of up to date operation and maintenance contract 77 Tight Tank �� Copy of DEP Approval Other d2zQ APPROXIMATE AGE of III gomponents, date instalfed{if known)-end source..ofwiformation: , Sewage odors detected when•arriving at the site:(yes or no) revised 9/2/98 Page 6of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ProgeMAd-&a.": 95 Windswept Way, Osterville DYi1e" Jean Ferrone Dot,or 4upacZiort: 6/9/9 9 BULLDWG SEWER: (Locate on site plan) 1 Depth below grade:.d JJ Materlaf of construction: _cast Iron 40 PVC_other(explain) Distance frorq,�rivate water supply well or suction line .� Diameter Jjj��'' C ments:(condition of joints; vantIng, evidence of laakaga,-etc.) m Joints appera s c TANK Vent . (locate on site plan) Depth below yrade:r,`_ Material or construction: concrete4l� fnetaloOLAFiberglasW/}Polyethylene ther(explaln) If tank is (metal, list ape Is.aga.conl1imed by Certificate of Compllance (Yes/No) Dimenslons:l t2sY6-g-�Sludge depth:_ — Distance from to sludge to bottom of outlet tea ortroffle:� Scum Wcknsss: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to'bon of outlet tee o battle --LG�/�i How dimensions were determined: Comments: (recommendation for pumping,condition of Inlet and outlet tees or•baHies, depth of liquid level In relation to outlet invert, structuto"ntegrity evidence of leakage, etc.) Pump tank anniin11 ;E f'arh2ae dj®p^6&ej resent . Inle , the Outlet in-ar-r Js n so n an GRFASE !220,1 IOU (locate on sits plan) Depth below grader Material of cons truction.l concroWa motalXAFiberglassiU,�Polyethylenet�other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet too or baffle:, Distance from bottom of s um to bottom of outlet tee,or baffle:-e!�g Date of last pumping: Comments: (recommendation for pumping, condition of Inlet and outlet toes or baffles, depth of liquid level In rolotion to outlet invert. structural int.grity evidence of leakage, etc.) Urea., tra i revised 9/2/98 Page 7orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(co(rdnued) Prop"Ad&&U: 95 Windswept Way, Osterville Owner; Jean Ferrone , oats of Inupection: 6/9/9 9 TIGHT OR HOLDING TANK;! (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:414 Material of cons tructionA?A concrete+fjmetal,{J�Fiberglas&4*-Polyethylene4{ kother(expiain) .414 Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm I_Inworking order:Yes4V No� Date of previous pumping: 1010 Comments: (condition of inlet tee, condition of alarm and float switches,etc.) 11grit or holding tanks are not Present DISTRIBUTION BOX:_V (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note-if level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) Distribution box has two lataralg at n annal flnur Nn Quidance of gn1 ; r•arry n..or . -N1e e-videfiee e€ leekag-e— ift�-e—o-x�-out of the bx _ PUMP CHAMBER:, (locate on site plan) Pumps in working order:(Yes or No) 41,4 Alarms in working order(Yes or No)_a Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropenyAdclress: 95 Windswept Way, Osterville. Owner: Jean Ferrone Data of(nspecoon: 6/9/9 9 I SOIL ABSORPTION SYSTEM(SAS)_4, 00?gAVd U A64.4ahA'� (locate on site plan,If possible;excavation not required,location may be approximated by non intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries, number: leaching trenches,number,length: leaching fields, number, dim Ions: overflow cesspool,number: Alternative system: A� Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to cnnrga sand .Ne s}ses ef hydradlie faj aLu or PO"IRS - 99ils are • nOrmal . CESSPOOLS: � (locate on site plan) Number and configuration: Depth-top of liquid to Inlet Invert: Depth of solids layer: AW Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow (cesspool must be pumped as part of Inspection) Cesspools are not present . Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of.vegetation, etc.) Cesspools are not =rpgpnr PRIVY:"2vI✓ (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, revel of ponding, condition of vegetation;etc.) Privy is not present _ i revised 9/2/98 . Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM LRFORMATION (corrtin.roC) PTop--ryAd&—: 95 Windswept Way, Osterville °r"'" Jean Ferrone 6/9/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include t),s to atlasst two parmanant Islaranca landmarks or benchmarks louts all walls wiNn 100' (Locate wham publIc water supplY comas Into house) Centerville Osterville Marstons MIlls Water . Company 428-6691 slleAr lo � ' revised 9/2/98 Pip 10of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 95 Windswept Way, Osterville owner: Jean Ferrone Date of"Pection: 6/9/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater A— Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record �' Observed.Site (Abutting propert observation hole, basement sump etc.) t- Determined from local conditions Checked with local Board of health Checked FEMA Maps zhecked pumping records ;e;checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water Contours map . Gahr ty & Miller Model 12 1 i revised 9/2/98 Page 11of11 - r f•r•nnT�nITT."'.T—\TI'•x'A•I.mlTnnflAJn1111'1"1nnl/AR'nR.1AR01.1ti��•Ilef1 — .T'1'•Tr.Tren��..t-.r..,, 'I'OWN OF $ S BLE WARD OF HEALTH 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D — CERTIFICATION l>�•Tf1�T••. .:.—�.1 IIt�.RI'.\T rA'11.'TIP'\RIRT/ITInT.�—.\7 r\IR\R�RR1r'TT��i/�1�T\ 11T 11 T1TT�1'.1 -TYPI OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 95 .Windswept Way, Osterville ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Jean Ferrone P,ARV D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & Son', Inc . COMPANY ADDRESSBox 66 , Centerville Ma . 02632-0066 Street Town or City State-tip COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that t11e information reported is true , accurate , and complete as of the time of The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public he-aW, or the. environment as defined in 310 CMR 151303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con�cted has found that the system fails to Protect the j-)tlblic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date 1 � One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF- .11ZAL1'll. IC the inspection FAILED, th`e owner or'"oporator shall upgrado ' the ayetem Within o'ne year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CFJR 16 . 306 . partd . doc TOWN OF BAFNSTABLE LOCATION . �Jb )l Y)A/s2y9enT- 4. SEWAGE # VILLAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ��� (size) NO.OF BEDROOMS_ BUILDER OR OWNER PERMPTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist- within 300 feet of ea�cg fa '' ) Feet Furnished by Y ' t V i � � Z �. ka e " i f� LOCATION SEWAGE PERMIT NO. k6-r to 9s- VILLAGE L- i D fl S 11 R S NA E A D E S S IN TA E M BUILDER OR OWNER M�1C F (ZRo 3 F� DATE PERMIT ISSUED ��f��`j DATE COMPLIANCE ISSUED IL - 1 OT �� . � 4r � .� .` d �, . � crj c.0 • W W �., II. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .� r'�.............oF- As' k�C��`�--................------ ApplirFatian for Diapaii al Workii Tonat urtiun rxmit Application is hereby made for.a Permit to Construct (V-� or Repair ( ) an Individual Sewage Disposal System at: ...q ... r . - ............ --- ................... Location-Add ess /or Lot No./-, / ..�?! r✓ rt l 2cl�fT............................... WQy Y S7d16� Owner Address Inst Iler Address d Type of Building Size Lot. eS,:5(:0-.-.Sq. feet U Dwelling—No. of Bedrooms___...............:....................Expansion Attic (1U Garbage Grinder j Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ...........................-- .----------------------------- W Design Flow--. ..gallons per person p@ r day.::Total daily flow.._..�a. . ......................�allons. L> WSeptic Tank—Liquid capacity.1.5- allons Length_i 3-P 1($_._ Width.- -.e _. Diameter---------------- Depth_D'. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area............_.......sq. ft. Seepage Pit No.......`_�........... Diameter--_--��.......... Depth below inlet.._�j ta........ Total leaching area...CQ.i. ....sq. ft. Z Other Distribution box (ys Dosin tank ("0 ` a Percolation Test Results ` Performed byi? ..� __1+�.4._C�-_........_.. Date.. __ �___.______.. ,,..a Test Pit No. 1...�Z.....minutes per inch Depth of Test Pit___-? _-__....... Depth to ground at r. d.4'..�,14 Qc3i..4, b (T4 Test Pit No. 2...,'_' ` _...minutes per inch Depth of Test Pit....SZ........... Depth to ground water---LIC) .Gsu.Kcu,.c't�"P 04 ...................................-----........................................................... -----•--•--- -.----- ---.-..-------.-- 0 Description of Soil......Q-2......L��_�.V+-'d. s Q.is .u._.... � �� 1�_��1�---.......`��.......--•------- U ----------------------------------------- --------------------------------------- -....... •-------•-------------•-----------------•----- W --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------••----...... UNature of Repairs or Alterations—Answer when applicable............................................................:.................................. Agreement: . The undersigned agrees to �taforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL%, 5 of he State Sanitary Code—.The undersigned further agrees not to lace the system in P Y g g P Y operation until a,Ce ificate of Compliance has been issued by t board of health. - Signed------ ------- --------- --------•------•------------•--.----- an toq , Application A roved By__. .................•----•-•---- J Date Application Disapproved for the following reasons:-------••------------------•----.....------------------•----...--------------------------------------•-•------- .......-•-----•-------------------•---------------........_...-•------•--.....-------•-------.........._.............---.....--------------------------------•---------------------------...........-•--- Date PermitNo................................................... -- Issued....................................................... Date Ir No....... .._...... r y Fss_.....-�...._ THE COMMONWEALTH OF MASSACHUSETTS —�--�-- BOARD OF HEALTH Appliratiun for Disposal Works Tonstrurtiun Permit Application is hereby made for a Permit to Construct ( y�l or Repair ( } an Individual Sewage Disposal System at• ...-I� - 'a' ---- -- ... ..... ......... .................. ...... . A srr..._..--------- --- --- - ---....-- --....... ion-Address ----- - - r Lo No Q� )W��� ...- �,// Owner Address a /1'E'Vr. .............. .Gfd`4�•• .... ....... ........ ...:........ ............... Installer Address + Type of Building Size Lot_.' :. _...Sq. feet a Dwelling—No. of Bedrooms.._... ----------------------------------Expansion.Attic ( Garbage Grinder (�c5 S p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) aOther fixtures ............................................................... Design Flow...`J{J __ ? o::.` 5_ lons per person pgr day. Total dail flow......G.�d....................... 1 sr Septic Tank—Liquid capacity.5._._ alllons Length.A©'�.. Width..-��--=_.. Diameter..-""......... Depth_ �.. x Disposal Trench—No..................... Width..................... Total Length-.------. .-.�--. Total leaching area...................sq. ft. 3 Seepage Pit No....... ........ Diameter.....1 ......... Depth below inlet...3:5.._..._. Total leaching area..l �...sq. ft. Z Other Distribution box (�i Dosi 1 Percolation Test Results Performed by ........ .C............ Date.... .. .. 2 ......_..... ,.a Test Pit No. I...GZ:....minutes per inch Depth of Test Pit...,Z_........... Depth to ground wat r.. v%�...tc0-0 t rL5v1 f4 Test Pit No. 2...K.'...minutes per inch Depth of Test Pit.... .......... Depth to ground water.......................J a ---•------------ - ....- -----•••..... ..... - 0 2, Low.� v �. 2. - r Description of So>a.......� .' ........--•--•-••-•--•--•• •• � ....-- V ----------------------------- ---- .---•---.--------------------------_.------------•--._.......... ....--------•------- •---- .-.----......... x UNature of Repairs or Alterations—Answer when applicable.........................................................:..................................... -•--------•.....................•---••-•------•--...------.........-----=--.........------..........---••---........----•---------------------------........--------•-••----------------•••-•---•----... Agreement: The undersigned agrees th aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of e State Sanitary Code—.The undersigned further agrees not to place the system in operation '1 a Cer 'ficate of Compliance has been issued by the board of health. ..... --,Signed ................•- ------------...-------..._..-•----•----•--•--........---._ ................---.... i' ate Application A roved By.. __� ......................•-•-•-••••••••••...................•••••... ....................................... Date Application Disapproved`for the following reasons:----•---------------------------------------------------------------------------••-••-------.........••••.---- .............•------••--•----••-•--••----•--••--••••..............---•-••--••----•-•-•----......••-•-•-•---....---._._........._...--------•---..............._......----•----......----•-............_ Date Permit No..................................................._.._ Issued...................................................... _ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (Urtifiratr of Tomplittnrr THIS IS TO C IFY That the Ind vidual Sewage Disposal System constructed ( ) or Repaired ( ) by--------- .-----.�C: `/�...__. ..................................................:.............................................................. ......._ d ----✓ .... Installer ` at............ ...-.. o � -' - use ....-•-----------------•---•----....................._._._.... has been installed in accordance with the provisions of TITLE„_5 o he State Sanitary Co s de rib the - �/9 � � jg ��'� application for Disposal Works Construction Permit No......................................... dated.........__... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. -.......-DATE..................)..I*--- b"6........................... Inspector..............--- ...................................... .......r........... THE COMMONWEALTH OF MASSACHUS&TS BOARD .OF HEALTH No.`��'.................. r...........................................OF........-•----------......................------------•-----•-----•--................ Fg$..... .... Maps 1 arks4"X#r1rtiurt Permit +� f- Permission is hereby granted---------=-------------•-••-•----.....-----...--•----.. '................................................................................_.. to Construct ( ) r epair ( ) an Individual Sewa a Dis sal System c 1 W „ � f _K �treet - as shown on the application for Disposal Works Construction frnit f,:. t'd......................:.................... 0 •---••-•---•••..----• •-•....._ ..... . .......:... --------..---------•-....- r ' Board of Health DATE................ $$' <.h,: ............................ FORM 1255 A. M. SULKIN• INC.. BOSTON • job r • sz�t � .�, .�x/S7 • p -. r�x/y . to 7 I / :P/ 33• OF Mqs� o q PETER R SUL VAN i 1� 29733 to .� / /_ 5 / 10 C� 7h//.S 4,,V r41,/ iCE'G/S7''��2EO .C.4.c%O SU.eY�y� /N.S7-.e!//ICA- 17'SZ/, A.,1.14/C,q,117" �i A n 7 ,.y,.,, x $s LOCATION Vol, 1 S E W A G E PE RMIT. , Na VILLAGE S7—tjzv LL INSTA LLEk'S NAMEµ A- ADDRESS 1 4 e U I L D E R OR OMrNER .� S Q / DATE PERMIT ISSUED _ DATA COMPLIANCE ) SS0ED'y M vim. CoJ- s } TOWN OF BAPNSTABLE LOCATION v' 1 f-)A a i,l,'i�Je IJ F U Z4 SEWAGE# VILLAGE i ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE_NO. SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type), (size) ,mil NO.OF BEDROOMS _ BUILDER OR OWNER -/Ta Z` PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leach* g Facility(If any wetlands exist within 300 feet opeac g fad"' y) /; Feet Furnished by i' � 1'/���� �2Ds' Phi. q ' U)ql sN4� U)q y r I r ' s r M _ M I (1 wo �4 ( } goo ►J 1 t , ' .. ✓ _ `ram,,. a i c.� 4 5 �c 1 i PLAw VIEW i Si W6-LE FAMILY ---- 4 CSC o iz.0o M's � rH C-AR i3,4o" . C ER,TI F E Q P LQT Pt_A,t\3 DAILX FLbW t 10 x 4 = 440 x r 5c C1.00 6,p. C). 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