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HomeMy WebLinkAbout0106 CRANBERRY RIDGE ROAD - Health I I T, Cranberry Ridge Road Marstons Mills A= 031-018 r i cam, Commonwealth of Massachusetts Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name / information is required for every Marstons Mills V MA 02648 04/19/2021 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. Imngoutforms A. Inspector Information ► -S�gLf filling out forms on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. .... ... ..... ..... ... 52 Rivers End Road rQ Company Address Teaticket Ma. 02536 Citylrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 04/19/2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `.;�„ � 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a precast leaching pit with stone. At the time of the inspection there was apx T of ponding water in the leaching pit and no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is Marstons Mills MA 02648 04/19/2021 required for every 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.7/26/2018 Title 5 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 ..............<V 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c / 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow El E 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 in = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Cranberry Ridge Road —u- Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. Cityfrown 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? r Have large volumes of water been introduced to the system recently or as part of ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33 plus GP Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2020-90,000 gallons were used and in 2019- 53,000 gallons were 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 - Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Per owner tank was pumped apx 3 weeks ago 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 r c Commonwealth of Massachusetts M1 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 13"feet Material of construction: ❑ cast iron . ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet III Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. There is a dehumidifer in the basement that discharges to the outside. Pipe is visible from outside. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is Marstons Mills MA 02648 04/19/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 3"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1000 gallon Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle was in place. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,V b� 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is Marstons Mills MA 02648 04/19/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road � errY 9 Property Address Melinda Caron Owner Owner's Name information is Marstons Mills MA 02648 04/19/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. it t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L � 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2019 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 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, m it( g y p g, damp soil, of vegetation, etc.): At the time of the inspection there was apx 3' of ponding water and no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): II t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is Marstons Mills MA 02648 04/19/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t 'On:wwod .'YO '. A 3 t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 f . c Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You, must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c � 106 Cranberry Ridge Road Property Address Melinda Caron Owner Owner's Name information is required for every Marstons Mills MA 02648 04/19/2021 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 ® 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 L 5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form COPY Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137. Owner Owner's Name information is Marstons Mills every page. Citylrown MA 02648 December 14, 2009 required for State Zip Code Date of Inspection i Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important: A. General Information When filling out 1 forms on the I computer,use 1. Inspector only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc Company Name PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 Cityrrown State Zip Code 508-888-2805 S112843 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 expertgnce in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority December 15, 2009 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. Title 5 Official Inspection Fo Subsurface Sewage Disposal System-Page 1 Of 1 106Cfenbeflyridgerd �� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Cranberry Ride Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is Marstons Mills MA 02648 December 14, 2009 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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: B) System Conditionally Passes: ❑ One or more system components as described in the" onditional Pass"section need to be replaced or repaired.The system, upon completion the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y, N, ND) in th for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 y rs old"or the septic tank(whether metal or not)is structurally unsound, exhibits subst ial infiltration or exfiltration or tank.failure is imminent. System will pass inspection if the isiing tank is replaced with a complying septic tank as approved by the Board of Healt "A metal septic tank will pas inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating t t the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or h static water level in the.distribution box due to broken or obstructed pipe(s)or due to a br en, settled or uneven distribution box. System will pass inspection if(with approval of Board Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed Titic s official Inspaction Form:subsufwace Sewage VISP05al System•Page 2 of 2 106cranberryridgerd-03108 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is required for Marstons Mills MA 02648 December 14, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced . ND Explain: ❑ The system required pumping mor an 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(wit an of the Board of Health): Elbroken pipe(s)are rep aced ❑ obstruction is removed ND Explain: C Further Evaluation Is" Required b the Board of Health: q y ❑ 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 man r which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surfa water ❑ Cesspool or privy is within 50 feet of a rdering vegetated wetland or a salt marsh 2. System will fail unless the Board of alth(and Public Water Supplier, if any) determines that the system is functio ng in a manner that protects the public health, safety and environment: ❑ The system has a septic and soil absorption system (SAS)and the SAS is within 100 feet of a surface wa r supply or tributary to a surface water supply. ❑ The system has a se p' tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a eptic tank and SAS and the SAS is within 50 feet of a private water supply well. loscranberryridgerd.03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pago 3 or 3 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sys tem Form.-Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is Marstons Mills MA 02648 December 14, 2009 required for State Zip Code Date of Inspection every page. Cityr town B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): F The system has a septic tank and SAS and the SAS is le 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 analysi , performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fai re criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each-of the following for all inspections: Yes No El ® 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 El than%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. 1o6cranberryridgerd•03M rdle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information isA 02648 December 14, 2009 ll required for Marstons Mills State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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 ea of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet o a surface drinking water supply ❑ ❑ the system is within 200 f t of a tributary to a surface drinking water supply ❑ El Area system is located ' a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a apped Zone II of a public water supply well If you have answered"yes"to any que ion in Section E the system is considered a significant threat, or answered"yes"in Section D abov the large system has failed.The owner or operator of any large system considered a significant th at under Section E or failed under Section D shall upgrade the system in accordance with 310 R 15.304. The system owner should contact the appropriate regional office of the Departm t. Title 5 Official Inspection Form:Subsurface Sewage Disposai system•Page 5 of 5 106c ranberryridgerd 03108 &\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'L 106 Cranberry Ride Road Property Address Barbara Pina P.O. Box 1137 - Owner Owners Name information is Marstons Mills MA 02648 December 14, 2009 required for State Zip Code Date of Inspection every page. City(town C. Checklist Check if the following have been done.Yo 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 receil fed normal flows in the previous two week period? Have large volumes c if 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 inspectE d 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 own qr(and occupants if different from owner) provided with information on the paper maintenance of subsurface sewage disposal systems? The size and location n of the Soil Absorption System(SAS)on the site has been determined ba ed 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 dis nce is unacceptable)[310 CMR 15.302(5)] Title 5 official Inspection Form:Subsurface Sewage Disposal System•page 6 of 6 f o6aanberryridgerd•03= I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Cranbegy.Ridge Road I Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is Marstons Mills MA 02648 December 14,2009 required for State Zip Code Date of Inspection every page. City/Town D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No 2008= 156 GPD Water meter readings, if available(last 2 years usage(gpd)): 2009= 123 GPD Sump pump? ❑ Yes ® No Current Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the T'le 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 ta6uanbefrytid9erd 03/OB Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form --Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is Marstons Mills MA 02648 December 14, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Ready Rooter records: Pumped 07/10/09 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: System installed 07/25/1989. As built and Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No 106cranbenyridgerd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owneft Name information is required for Marstons Mills MA 02648 December 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 16" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 8,1 i Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'X 4.5'X 4.5' 1000 gallons Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. 106cranberryridgerd•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is Marstons Mills MA 02648 December 14, 2009 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet PVC tee and outlet concrete baffle in place. Liquid level at outlet invert. No sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal /irg ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to p 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.): Tight or Holding Tank(tank must be pumped at time of ins ction) (locate on site plan): Depth below grade: Material of construction: R ❑ concrete ❑ metal ❑ fib glass ❑ polyethylene ❑ other(explain): 106cranberryridgerd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is Marstons Mills MA 02648 December 14, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: /El llons Design Flow: llons per day Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet, no high water staining or solids carryover. Light roots removed from D-box during inspection No effect on system operation Cover within 8"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 106cranberryridgerd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'' 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is required for Marstons Mills MA 02648 December 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6'X6'w/3'of stone. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level in leach pit 5'8" below invert. High water staining 5' below invert. Clean stone visible through side walls. No sign of past hydraulic failure. Cover within 6"of grade. 106cranberryridgerd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts a 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is required for Marstons Mills MA 02648 December 14, 2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate on site plan): ( p ) Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs o hydraulic failure, level of ponding, condition of vegetation, etc.): 106cranberryridgerd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .." 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is required for Marstons Mills MA 02648 December 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. t � \ II � I lA i r • �2 D6 3 106cranberryridgerd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 106 Cranberry Ridge Road Property Address Barbara Pina P.O. Box 1137 Owner Owner's Name information is required for Marstons Mills MA 02648 December 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells >5' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 05/25/89 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: No ground water encountered in test hole for system instalation (1989). Accessed local ground water contours and topo mapping. Property elv= +-100. No high ground water in area of system. 106cranberryridgerd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 TOWN OF BARNSTABLE LOCATION R EWAGE#&<� �n VILLAGE 1-A,,��g,.< ASSESSOR'S MAP&PARCEL 03t ro INSTALLERS NAME&PHONE NO. C.3 , vv\, SEPTIC TANK CAPACITY ( 0 Od A . LEACHING FACILITY:(type) (size) NO. OF BEDROOMS 3 OWNER PERMIT DATE: 5��f � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility / Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) _ ^D A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) /I/ Feet FURNISHED BYJ— 1 Qn:VGw.AK iYO \ R 00 7 0 3 ®r 3 11 09�©" fl, T QI O BA STABLE y R1,06C OO LOCATION SEWAGE # / �� VILLAGE> 41491 ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO. 4)A AI WO? 778 2?T SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �p (size) NO. OF BEDROOMS- PRIVATE WELL OR UBLIC ATER ` BUILDER OR OWNER DATE PERMIT ISSUED: } DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No J . � �.z-� �� �,�,� - �� L � � p /��' , Z���� ' - __ Fms....,t�.,. .......... P 91 THE COMMONWEALTH OF MASSACHUSETTS BOARD O/F� HEALTH ... .... w ..............OF....4... /....e���77-fl...!��----------------------------- � 3 1 ' i4lPfiration for U,ispasal arks nn�strur#tun ramit vApplication is hereb made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal _' y ........... .. -' ,. Location.Address or Lot No. ... ------------------ ------------- ---------- •--._...............--••-•--.-- ---...------..._............._................ - .Address Installer Address Type of Building ize .......Sq. feet U Dwelling—No. of Bedrooms ..............Expansion Attic ( Garbage Grinder 0A Other—Type T e of Building yp g ...... No. of persons____________________________ Showers ( ) — Qafeteria ( ) Other fixtures .............•-••--•---•-••-•-_... ......•-••--............-•--•--•--••--•---------------••-•••--•-•-•----..... � . ..__..... ......._.......... WDesign Flow..... � ..............................gallons per person day. Total. flow._.....3 --®--------------•----•-dons. WSeptic Tank—Liquid capacity.20M.gallons Length..._!6.... Width..__�L.... Diameter................ Depth- _._..._...... x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No.P...4/�... iameter...lQ........... Depth below inlet...._�o.............. Total leaching area.-4........sq. ft. z Other Distribution box (t/e Dosing tank ( ) r 0-4 a Percolation Test Rests /Performed by.._�f.f._ml,f _! ..................................... Date_.4_/__°`.. ._._............. a Test Pit No. l................minutes per inch Depth of Test Pit..k3----------- Depth to ground water..�®............ 44 Test Pit No. 2...6............minutes per inch Depth of Test Pit.................... Depth to ground water........................ W -•••--•-•--•-----------•-----•........--•............••-•------•.....---•-..._...----•-•-•----------......................................................... 0 Description of Soil........................................................................................................................................................................ W V ----------------------------------------- -------------------------- ._...-------- ._.---------- •-------- ----------- •---------------- ...----------- ..........--........ ---------- W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •------------------------------------------------------------------------------------•........---...............--------------------•---•--••--•----•--•-•--.........-•---.._.............._....--...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenn is d-by the of lth. Signedh °�'?' ._ / ._ . � - Date Application Approved By...........ael . ..e....�.,�� •---•-�'" e/ f Date Application Disapproved for the following reasons:-------••------•.............................•------•--------•-•-•------------.........----••...._....---....._ --•-••-•-•-•---•.....................•----•-•--•----•-------------.........---•-•----.................._.............--•----•------------------------••----------------•••------••-•....•..----•-------. Date ov Permit No.._... ... --------------- Issued..---------•---•••_.. D....................................................... t No..g..k?-r�Lf, '" Fss.... .... .., ;. E COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ,.. . .............OF.... { J... ................................... , ippliration for 14sposal Works nntrurtiun Prrnti# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: !! /�`. d�`f !'!:��2. .../(/-� __.f.&-rcr..'1_...--------1'-q.....---- Location-Address Lot N,.. or o. ••... —^•- - �..� zC ----•-------.--•-------------•---------- ••---.....--•---•----.........................--- ess.......g- ' Ow er Address W _.. � Q _ - -- -----------•--...........-•-•._ ................-----..........---..---------........._......... ....._......--.--............. nsta e —Address Type of Building Size'Lot_-'3- 0.1! Sq. feet U Tr Dwelling—No. of Bedrooms ............................Expansion Attic ( Garbage Grinder (R/l pa, Other—Type of BuildingA✓ �-t.. ""___..'._____ " ...... No. of persons............................ Showers — Cfteria P ( � ( ) d Other fitres . -• ----•• •---•-........... -•••.•.... WDesign Flow...... . .:............................gallons per person_per day. Total daily flow.......� Q......._ .............gallons. WSeptic'Tank—Liquid capacityes -_gallons Length - 'i�-_-_ Width.c:6.... Diameter ............. Depth_-,y...--.__. x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage,Pit No..&.!(,e 4: .... ,iameter...eO.......... Depth below inlet.....6.-.......... Total leaching area... ....s, q. ft. z Other Distribution box ( Dosing tank ( ) ~' Percolation Test Results Performed by---- 1 ? ./.................................•... Date.. e.f�..�`_._..._.___.._.. a Test Pit No. I...' ..•.-.__:_tnmutes per inch Depth of Test Pit.-/.L.......... Depth to ground water...A110............. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................... ....................---------------------•-•---•---•----.........------•---- .....................................-......-........................7...... Descriptionof x Soil-----------------------•----.......---....-----------------•--=•----------....-------------••-----....------......------.............--•-----------•---......--........ ' U ...................:....:................... ....................................................................................--------- ._........._............._........__•._____......._.....___•___. P U�l ...............I...........__........._._..._._......._.......................---..............................................._...................................:.................................... 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 TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss a d by the board of lyalth. Signed;,ice ./ . Dat , Application Approved B ` PP PP y---......... K Application Disapproved for the following reasons:............................. ..........................................•-----------•----.....---------•-----.._..-----..................... ...................-...................................................... Date Permit No..... ��'�......'�,..� ..................... Issue(L.......... •--•--•-- ... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................O F.. ft.! ..J r� :......:.............................. Tntif iratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) at......- .7.-• •_ :6 -•--••- •- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......$91-!t_;k./.y........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................:........•••-..........----•------....... Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �Q� I cpile-14..............OF........... ............................. f--..a - .y FEE. • ....... Disposal Works Tonstr uan--prmi Permission is her by gran ,ted......... .9.-77......O/A C r to Constructor Repair an Iijifividual Sew a a Di osal S treet as shown on the application for Disposal Works Construction it N ....._........ --_ Dat ----------------------------- ...... DATE................. / • ...................•--. _ o of e l FORM 1255 A. M- SULKIN, INC. 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