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Home My WebLink About0063 FOXGLOVE ROAD - Health 63 FOXGLOVE A MARSTONS MILLS A= 149130 y � I 71 21y 2 c 2 o -o�?e i I f TOWN OF BARNSTABLE LOCATION G 3 V-0 X G VE RJL SEWAGE# 2020- 0 38 VILLAGE 1c. �� &ESSOR'S MAP&PARCEL '��` ��0 -0I2 INSTALLER'S NAME&PHONE NO. B l� G EXca,%io.A i OJT y 1'1.OG 53 SEPTIC TANK CAPACITY /,500 -rAtiK i ., BoX rcPlo�ccrr cr�� LEACHING FACILITY:(type) (size) NO.OF BEDROOMS dJ I a-- OWNER —0,av�ok QoncL PERMIT DATE: 2-3-20 COMPLIANCE DATE: U 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY At- Iq ' t A3'.25 Ay. 33 z, AS- Vconi y3 O �, ry2►L�� O 45_ GZ G„ s 3 n No. 20 Zo ®-39 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS RpphLatlon for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(%4 Upgrade( ) Abandon( ) ❑Complete System [Individual Components Loca)rs dress or Lot No. (03 0 x G1 OVc. Road Owner's Name,Address,and Tel.No.Watt tr 4 Tanic L Asse§sap/Parcel � , YY1 rlo�d In roX Gtavc (Zd (� �(Utt1L Installer's Name,Address,and Tel.No. 1b 1 S. Designer's Name,Address,and Tel.No. %14 F100+o ISO NA Type of Building: Dwelling No.of Bedrooms b2t Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided AA— gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank I sd U Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)% _T o.nlG gnd 0- boo l Ol act monk UNIu t< Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si Date Application Approved by Date 3 Application Disapproved by Date for the following reasons Permit No._&7,0 03 Q Date Issued No.�� O ✓� 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Disp9so 6ppte4onstrUttion Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System [/Individual Components 4 Location ddress or Lot No. (�3 F X (� o,!C I o c"d Owner's Name,Address,and Tel.No.\p jc,r r c e T,,n,t II C r'+p/Parc 1�j0 el U)� 7 , Asse§s1 s Ma �� Y1'1(� P1 a n r1 (02, �-o tr,l uv c (�ci C n nl r u t a Installer's Name,Address,and Tel.No. (�j 3 cC y C 0,a Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms A jr} Lot Size sq.ft. Garbage Grinder(N o) —moo Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided A)tQ. gpd ' Plan Date Number of sheets Revision Date 4� t Title Size of Septic Tank 1 Sd U Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)X n f 1• b o> a n ,r k l Date last inspected: Agreement: ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig Date Application Approved by (i Date Application Disapproved by Date ` for the following reasons i Permit No. 03 a Date Issued J _______________________________________________________________________________________________________________________________________ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓) Upgraded( ) Abandoned( by 3 i r r ra.,r.� a �tj r. at_(�r L�,,,i r P n r ,{ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoZO -- 030 dated Installer (� �.Y r n .,,n� ,� MOc Designer #bedrooms NA Approved design flow} gpd D notion es' ed. The issuance of this permit shall not be construed as a guarantee that t�e system will Date Ispector ------------------------------------------------------------------------------------------------------------------------------------------------------ No.2020 —o3$ Feel 5,4� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal Epstein Construction Permit Permission is hereby granted to Construct( ) Repair(V) Upgrade( ) Abandon( ) System located at D and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by _ _ I ' i�9-yap-�a- c°�,��, Commonwealth of Massachusetts �n Title 5 Official Inspection Form 51. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 63 Fox Glove Road Property Address ; Warren&Janice Rand Owner O e =� information is s C Ma 02632 1-6-2020 required for eve I page. Cit /To State Zip Code Date of Inspection , Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 us Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 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 Brett Hickey "'re-ao,a`a"�"� 1-6-2020 o�:m.�on �.o.a.oma,-ofl��ma�.a. �s te:2030.01.00 i02J:Of OS'00 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.7/2 612 0 1 8 Tide 5 Official Inspection Form: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 ........... 63 Fox Glove Road u- Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 - 1-6-2020 required for every 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: 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): Septic tank showed signs of substantial exfiltration at time of inspection. Tank only had 3" of standing water when viewed. D-box was also in poor condition and is in need a replacement. r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 0 distribution box is leveled or replaced ❑■ Y ❑ N ❑ ND (Explain below): D-box is heavily deteriorated. ❑ 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 Y( 63 Fox Glove Road u� Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ' ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Q 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 �m Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 63 Fox Glove Road u Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every 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 ❑ O Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Q Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ Ej Any portion of a cesspool or privy is within 50 feet of a private water supply well. El El 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- El 10,000 gpd. ❑ a 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 9 Commonwealth of Massachusetts Title 5 Official Inspection Form �^ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road v� Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question'in Section C.5 the system is considered a significant threat; or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No E ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the,system components pumped out in the previous two weeks? ❑ F,I Has the system received normal flows in the previous two week period? ❑ 0 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) x Was the facility o�dwelling inspected for signs of sewage back u ? ❑ ❑ p P Y 9 9 9 El ❑ Was the site inspected for signs of break out? l ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ a 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: El ❑ 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 i Commonwealth of Massachusetts 12 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road V Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes rol No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes R) No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes [E No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 283.5 / GPD last 2 years Sump pump? ❑ Yes ❑■ No Last date of occupancy: Jan 2019Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,q Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road V� Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- pumped 1 to 2 years ago Was system pumped as part of the inspection? ❑ Yes ❑0 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 cam, Commonwealth of Massachusetts �A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 63 Fox Glove Road u Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System,Information (cont.) 4. Type of System: El 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: Tank and original pit were installed in 1978 per plans. Second pit installed 1996 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron X 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: 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 .. Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road u� Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11611 Depth below grade: feet Material of construction: X 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 1 Dimensions: 000gallons "Tank leaking" Sludge depth: r� r� Distance from top of sludge to bottom of outlet tee or baffle rr rr Scum thickness rr r� Distance from top of scum to top of outlet tee or baffle rr �� Distance from bottom of scum to bottom of outlet tee or baffle viewed How were dimensions determined? on Comments( pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):, The septic tank only had 3" of water when viewed. Tank shows sign of substantial exfiltration. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts +� j1p Title 5 Official Inspection Form - I� Subsurface Sewage Disposal System Form Not for Voluntary As sessments 63 Fox Glove Road Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA 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 - III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 63 Fox Glove Road ul Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 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): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in poor condition at the time of inspection. The concrete is deteriorated. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * 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: El leaching pits number: (2) 6'x6' pit ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 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 63 Fox Glove Road Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Leaching was dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �v ,jp Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road v� Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road V� Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 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:. Al hand-sketch in the area below ❑ drawing attached separately C9 of I IA. r?..O In-5 OC>:2 TOWN OF BARt4STA13LE LtA I'rt=arr �(.3 F�,� >r�../��.-� _.- _ sEwAc;E #��/, �� ✓rI LA E L� &c °w y t"...^'1 ASSESSOR'S MAP &- LOT_ irasALLR s 1vAME I'Ilc3ia ...,, � ? __.... ✓ ._ 4 SEP'rrC TA.Ny CAPACr-f Y L.F...ACHTNG FACH_1717Y� (type) _l kt �a.?W _... <size) NO OF BEDROOMS B DF-R rrra vrwER � PERM I-rDATE: � �/�� 'COMPLIANCE DATE separation Distance.Between the, Maximum Adjusted Groundwater fable and Dottoxn of Leaching Facility 3 f Fcet Private Water Supply Well and Leaching Fas ility (if any wells czist � on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If 4241 y wetlands exist witlxin 30 feet of lehing facility:) !Feet Furnished by_ _'% ;y . - r-.r z '• 3. o Y3 .3 6 a �� v�r-.cam t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fox Glove Road Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: K Check Slope ❑ME Surface water Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 13'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 2-6-1978 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official lnspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - J P Y Y 63 Fox Glove Road Property Address Warren&Janice Rand Owner Owner's Name information is Marstons Mills Ma 02632 1-6-2020` required for every. page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0 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 l ❑■ 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 TOWN OF BARNSTABLE p V LO(:ATION 12.3 has[G&c R SEWAGE # ;�. VII LACE /101 ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. 110h161I.J, SEPTIC TANK CAPACITY vcV Gz+ L LEACHING FACILITY: (type) /p�>7 �� (size) & X/D NO.OF BEDROOMS BUILDER OR R 1' PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S f Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) t Feet Edge of Wetland and Leaching Facility(If any wetlands exist �/�l� within 300 feet of le hing facility) �'k Feet Furnished by 1 / r , !� 1 '. Q' � O Q1- y3 6 9a- a s, ,, . cam- �i.�, � �3"3� b . ay- ��2�" TOWN OF BARNSTABLE LOCATION' o SEWAGE # VILLAGE C-e-" ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY D y LEACHING FACILrrY: (type) 'L (size) J X NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i y, 4, Na'b" qx' No. Sd s Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS rication for Zig ool stem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(t/an On-site Sewage Disposal System at: Location Address or Lot No. i E:®ay ope • Ownner's Name,Addr/esand Tel No. Assessor's Map/Parcel f�j7�y1 Tc�v //� � • 7e-�il e., ,r�o pep - rd Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. I01141 ev-V6,7` 7 7/-P3f9 Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow ;3 gallons. Plan Date , _I q` ® Number of sheets Revision Date Title Description of Soil Nature of Repairs gr Alteratio s(Answer whe applicable) ✓ / ®�O ®`�O'� A�On� elre Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued Signed Date Application Approved b Date Application Disapproved for the following reasons Permit No. Date Issued '� ——— —————— -- —----- — `-------- 17— No. s +. ?' Fee THE COMMONWEALTH OF MASSACHUSETTS ! PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 4fpprication for Zigogal *pgtem Congtructton Permit Application is hereby made for a Permit to Construct( )or Repair( /an On-site Sewage Disposal System at: f� Location Address or Lot No. /q �x ��0 / Owner's Name,Address and Tel.No. Assessor's Map/Parcel Cyr!////� �� 'vw `. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. I Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building o No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Il a gallons per day. Calculated daily flow ::g a>s gallons. Plan Date ��i��— /� Number of sheets Revision Date Title l Description of Soil i Nature of Repairs or Alterations(Answer when applicable) 11s /� 7 �n k 2 a-c&Z r2 4446" i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance'of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued bye 'sZoar of Health Signed I/ Date ?� 3 R4 Application Approved by rl Date Application Disapprove for the following reasons r Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )orrepaired/replaced( on by Installer X,,rC,�2 Z,7 ZKZ C44y:5, at 4 -2 L 4 V 41i?iz4 r l�o ra fz'✓�i/ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constructi Permit No. - datedT Date Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE"THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. " No. ---�------------------- /31 Z_ Fee i� — Llf i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS �Digozar *pgtem Congtruction Permit Permission is hereby granted o ' it to construct( )repair( n On-site Sewage System located at No.# Street and as described in the above Application for Disposal System Construction Permit. "7- `3- Date � 7;;v The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. Date: "�� .� Approved by C-11 "' oard of Frealth i i k � i � S . [� �5t�.►.I n4T4. c�ILY�I..L— 1=AMtl-�( - 3 �_`•t�t�oM ' �'� �„/�+l Lam{ F=LfGW s 1lh rC '3 • p - u l AJ... Ux .1t.LL ptiGA 1150 S-i=. \9 1 GjCJ s ( 2.1S, + :�;-15, Q.P.V. Tc�rAl.- '17E.��IGtJ = 425 G.P.D. _T-oTA L. 1=>Al L.%( F"0%4/ = '3W 6.PD. 1 _ G>✓i1GULdT10L.1 Q&TE. : ( lll 2.J4t1a.!'O¢ LASS.. - 1 � P��P• N U(, ? f14 G4. ik �,� GL w � p :loo Gv,� �:�„�-�*, rr,�:•: PATE luv-S�i.! Sugscvc. M ; Iav ( j -r-A04K F l 000 `�� iuv tW D , GaL. 68•Z "4 LsAa" .A u FIT W�T'ii •i t a!� - SAA L� �•O 1 @.0' • C-aZTIFtED PLOT LOCATIO" M 4esrU►�� lAt�.,S, M,�, uo `% GV, pATt= CLWrIP TO A?- T14c_ 9'� 5"Ow u PtAw Rr_1=cc��c�. 1�E'.I:t_[�tJ CcaV1G'LYS vv l-V;-i �'ow►J cr t',,I�tiZ.IJSTD� F- RAU F� N t ct�tAR: � U,►JEl L Eri4 k # Y 5 § s � � � �:' � � +1�r��` u I s-� '� "'�n� S 2t a�..'J �}5v� ♦: �.'1-.+4,' Y�,.,.'F:. �_ < ,� :. .7 { ��'�i� w� ; S:y cG y �i y ;,.,,, x.ia4.Mr,-' '� x�` r icy , � tom!w y ir. /` ra "1 k,- t '� is P'�:r Y F.}..u` f k ¢ rsT R.. y a ff .", 4 diP '.'..,..t ,n 't 6 'k.•r.,•. ^'�'^ .-•s. ,Fk � 8`�S �CTCF . r�� ti�V�� `t "7.'?'4"'P,y. .w:.:'i„ y..�.�i+;}x^.. ..y :'yYR''9i + ' "3+. dirtrq�r'�s •is+,? Sy< f ::;,.3hr..:ti.,,�,i' .'- 'z`a;'_sw. ,h • ., ^„� d si ;`a; "'��..•�y�'` �. i ... I`� f .�' �. ,L F fk%,• 4f— '•-s"':f�.f ':,vi S '..".w S •}r z'Str` �'}y`3- 9 +�'.d �.Y6 .�.r .k¢ie 2 k _� .'t'i ?�`� # :'....s. -'..str •'em;? 7�. �++3w.`.'`` t +-,-,•'�,.. `=eeu•+ 3 ...` � `t4 F>- 3 �T k '�i. - 1'.. d_ a � �1��w �k��. �.�,x4r�aw�X�+�.�`jd. .ex�;* 4 ��'I''a�,�r�4? w � �,� �id�s� <.x �n .xL - �.. �'t�* -.::1 �'Y�� a :,mow• �-3 "�: ��., ey,1,,, '�._�q`S *AA� t ,.�vi�,,'�'„1.t� �� e :�l"0'�'� ��ak�•�� f_; `.° � D,��M= ��+-�1�� l��t� - '.� C ERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL 1VUIthS (,UNS IItU(;IIUN CEtt(11tT Wf1'11UU'I' DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 7 /�3l�6 concerning the property located at 6 �X ��®�� Gee (f meets all of the following criteria: /There. are no wetlands within 300 feet of the proposed septic system ✓ T re are no private wells within 150 feet of the proposed septic system le observed groundwater table is 14 feet or greater below the bottom of the leaching facility 2T Th a is no increase in now and/or change in use proposed There are no variances requested or needed. DATt3: SIGNED LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER I Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certined plot plan, this plan should be submittedl. r'°*;1p�,�,..,��s +�'. " ''u ��..� � - � �'��' �'�I?'fix' �'' � � � ' '"+tea ✓ ,r� ��.,"n 2•.�� f�� '��f+�� +,� ��{rp'��? � p„�� r*v R � 15�.,9' ��ls��'t x.;-d. a'F-'��:..� >.c...v� ,. �`-,..�x p. !74: .. . L/� . TROY WILLIAMS N SEPTIC INSPECTIONS ' ;.; 1> Certified by A Department of Environmental Protection �� _ ( 760-1819 40 Old B ver Road , South s,MA 02660 Commonwealth of Massachusetts ED Q lJ u Executive Office of Environmental Affairs Department of Environmental Protection WIINam F.Weld Trudy Coxe Gow"Kw .8scMary Arpeo Paul Celluccl David B.Struhs LL Goyef xx Commbsiomf SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION c / r J �uy suit JG.tn✓SS�C.✓ . Property Address G 3 /-- X /O✓e C '. �h��✓� 4 Address of Owner. 7ec/�n S , sS f e✓ Date of Inspection: 6 ,/a/ (If different) w Name of Inepeetor.--7-,';7,,y Company Name,Address aAd Telephone Number. / va63� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes _ eeds Further Evaluation By the Local Approving Authority Fails Inapector's Signature: Date: 6, /a/ / G The System Inspector shall submit a ce y of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: // A] SYSTEM PASSES: 'A (1J I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B1 SYSTEM CONDITIONALLY PASSES: A/ One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. 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,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 ponforming septic tank as approved by the Board of Health. t (revised 11/03/95) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address 63 Fox Owner. 3 G 1,U S S/�c✓ Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Al Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addr FOX �j/o Ue ess: �r. Owner. Date of Inspection: D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into or y system component due to an overloaded or clogged SAS or cesspool. N LQ�� 1. l�,3 ur,A S�� r K wcrc Fo�..�� Fu 11 i^y ��G� I: 71a�; /vrc cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in 0"op L is 11 than 6"below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 1� Any portion of a cesspool or privy is within a Zone I of a public well. N Any portion of a cesspool or privy is within 50 feet of a private water supply well. Al 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. El LARGE SYSTEM FAILS: A11141 The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6_, FU ?C U Dom" Owner. Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates / during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plane have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow A/The site was inspected for signs of breakout. , All system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ // SYSTEM INFORMATION Property Address 3 Fo x /I Owner. Date of Inspection: RESI`DENTLkU FLOW CONDITIONS Deus flow:33a aaLona Number of bedrooms: Number of current residents: 02 Garbage grinder(yes or no):-,(O Laundry connected to system `�� (yea or no):_LC S Seasonal use(yes or no): /VQ Water meter readings, if available: g S = 17 7 ' v N Last date Of Occupancy: d L v,�p/ Ok COMMERCIAL/INDUSTRiAi• Type of establishment: Design flow:_--gallons/day Grease trap present: (yea or no)_ Industrial Waste Holding Tank present: (yea or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER (Describe) Last date of oocupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: L� s�pJ�h ek�� for r S G�i cil G�c✓ System Pumped as part of inspection: (yes or no)�(O If yes, volume pumped: ¢aLlons Reason for pumping: TYPE SYSTEM Septic tank/distribution box/Boil absorption system Single cesspool Overflow cesspool Privy Shared system (yea or no) (if yes, attach previous inspection records, if any) Other(explain) A�P,P�R�O�XII.-MATE AGE of all components, date installed (if known) and source of information: a w.L Sewage odors detected when arriving at the site: dyes or no) /V 0 (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addream h �o X y�J J L Or. Owner. �4 U -C Date of Inspection: SEPTIC TANIi{:_L./ (locate on site plan) Depth below grade: Material of construction: Zconcrete_metal_FRP—other(explain) Dimensions: S xC.- x 6 p p p y 4 W a h . Shulge depth: / Distance from top of sludge to bottom of outlet tee or baffle: o? 3 Scum thickness:_-6Ld_NE Distance from top of scum to top of outlet tee or baffle: /Vo s C' .� Distance from bottom of scum to bottom of outlet tee or baffle: VO S Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) L i v( e ,, / h /i e- Oki C ! d S GREASE TRAP:/ /q (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP_other(ezplain) 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 h I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Property Address: 6 3 �o X q Owner. 'S v S S� L v Date of Inspection: TIGHT OR HOLDING TANK it/ 1-9 (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallona/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) i� Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc.) _ o lil e L o SLd ,j L k - 6 b✓ �� G / S J / /) h G PUMP CHAMBER /V/4 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 7 SYSTEM INFORMATION(oontinued) Property Address: 3 �o"c y/o cj e— Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):,z (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: leaching pits, number:01 -- Go S i3h c leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)_ L LJ 'X�w c�� 4C AT 2:77i" S � Mt 6J O K � CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: IV119 (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. � c_ 'v S -S �—e.rr— Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarla locate all wells within 100' i=rb �- ay 33 yy ya G �� 1W DEPTH TO GROUNDWATER Depth to groundwater: feet adjusted high groundwater level method of determination or approximation: L) S C, A /1/I c 5 1.o caJ h o 9 r LO' C.A-TION SEWAGE PERMIT NO. Rd a - 9 VILLAGE V /,5(Cf_,gcj , U/a INSTALLER'S NAME i ADDRESS o &� 4' 0 C Ez ►J BUILDER OR OWNER omm v a PRO � �s III DATE PERMIT ISSUED ` DATE COMPLIANCE ISSUED YOU Y max S love Rom( Nod .^ 3 _ _ . . THE COMMONWEALTH OF MASSACHUS.ETTS ii BOAR® OF HEALTH ...................OF.............PI .5� .�. ...........:x..__........ a Appliration for Dispoii al Workii Tonstinrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal SysW at: � .... _A�. __ - ..�. ..... 5 -..4 .....r. 1 ...................... ... .. . .. .. - •-_._ . ...... ._... ---- -- - L catiW-Ae �ey ,�j��' or Lot N!o%. .... ... :. ..Y!�:�:... _.. 5...........�1,_.............. ^r- ® ^.•Address ................... c:!;':X:::............................ .................................................................................................. Installer Address UType of Building Size Lot_._......?,_5r 4:..Sq. feet Dwelling—No. of Bedrooms.............3.........................Expansion Attic (Kj)b Garbage Grinder (hid) '_l Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------------------------------------------------------......---------------------------------------------------------------........------------------. d wDesign Flow.......... ��________________________gallons per person per dapy. Total daily flpow.......... ....................gallons. w tx Septic Tank—Liquid*capacity..62Q0. �2 gallons Length- ...._...___ Width... Diameter....... Depth_.. x Disposal Trench— . .................... Widtk..r................ Total Length....................Total leaching area..=.................sq. ft. Seepage Pit No........ ........... Diameter..... _._.......... Depth below inlet.....C........... Total leaching area.LZR ...sq. ft. Z Other Distribution box Dosing t nk ( Percolation Test Result2.. Performed by........... ._.._lV. ........ ..... �5... Date.....-C .. .4 .� -------C 14 Test Pit No. 1........ ......minutes per inch Depth of Test Pit.......3........ Depth to ground wat r... 1/LP/Z.._�.3 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ........... ........................... t r e O Description of Soil....----Qr . 4! " �'........ �� !_�' �� 1. _�. x 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 iITAU 5 of the State Sanitary Code— e undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ued he board"healt........ ............... ................................ D to Application Approved By........ '/rd -�,��i6% j��V.--------- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•------------------.....--....._ .............................•--------------------•-----......---•----------•---------..7.....--------------------------------------------•--------------------------------------------.....-----......_ Date I PermitNo................................................... Issued.................................................. Date OV FEic a ._ - THE COMMONWEALTH OF MASSACHUSETTS BOAR® 9F HEALTH aA� ......... .......OF._.......... ... AVVfiraffon for Uiupuottl Works Tons rurfuart Prruti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Is It: -- - .... cation-A ej¢ �/' !� !_LaJ6.ClJ...lY�.:� {LE _ �� 4_+: 6Qt. .........�..e::� . .._.. -••- ........ _ _._._.... ....• ---.. Qw Address Installer Address 2 Type of Building Size Lot-___� c__JZx". Sq. feet �-, Dwelling—No. of Bedrooms.............3..........................Expansion Attic (Q0 Garbage Grinder (JQ Other—T e of Building No. of persons........................... Showers a YP g ---------------------------- P - ( ) — Cafeteria ( ) dOther fixtures -----------••----------------------•------------•-----••--•---•-•-------••---•-------------------••••_--•- W Design Flow.......... ...........................gallons per person $er qay. Total daily 4ow__._.._. ................................. WSeptic Tank—Liquid capacity_IPQQgallons Length�?__t?_____ Width...-/.Yq.... Diameter------------- Depth... _ _. x Disposal Trench—No..................... Widtxi__r---------------- Total Length.................... Total leaching area...................sq.ft. 3 Seepage Pit No........ ----------- Diameter .6............ Depth below inlet.___��.___...._._. Total leaching area_.z._�.... ft. Z Other Distribution box (1/ Dosing-t�nls ( ) b W a Y ._... - ��......' ` Date Test Pit No. 1..... .......minutes per inch Depth of Test Pit----- ........ Depth to ground Percolation Test Results Performed watr_._.:. _._.� fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ri ........................................• +-••-••• _. O Description of Soil-•------..- �_____._..._Cb�rh-_-_---' �y agl�t"J(-�"--------s.." f� �£1�I U IM c.� ------------------- •----------------------------- --------------------- ---------- ------- ------------ -------- •--•------------- ---•------- -------- .......------------ •-------------- W UNature of Repairs or Alterations—Answer when applicable______________________________...._.______........._....__.___......._..._......_..._......._.. ..------•-----------------------•--••-----------------------------------•--•-•----------•---••-•--------•-----. ----------._.....-----------------------------------•------••--•-......•-•-••.....••.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?, . 5 of the State Sanitary Co e— e undersigned further a rees not to place the system in operation until a Certificate of Compliance has bee sued he alt °board ,he Siguq d----__-- --_ .. ---------•-- --- --------------- .......................... te Application Approved BY •= ram.. ...�� ?�-----•---•----•--------- ---��/�� Date Application Disapproved for the following reasons-.........................................-.................................................................... - •-------•••-•--------------------••••-----..........••-•-----......••--------•---•-••---....----•---------•-------•-•••-••----•-----•-•-----•-----------••----=--------•-•-•----------••••-----•----••-- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH . ..........................................OF................... ...... ..................*'***........ Trrfifirate of ilulrr THa ISQ CERTIoThat tIndividual Sewage Disposal System constructed �or Repaired ( ) by ..... .� ....-•----.-k----------------------•---=---------•---.-.-.....--•-----•-••-----.._..-----------------•-------.................._.....-------....._ Installer at.......... l.r...-- ....-•---_... X �GZ � ••--•---------------•--•--••••---•••------•--------•-----•-•-•-•••-•------•-••-•-•----------- has been installed in accordance wii the provisions of TITLE 5 of The State Sanitary Code as described in the 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. e� L / . DATE............................................1...... �1_..-----••-----....... Inspector.................r--&Z--A-.6=.............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �/� ........ 5"^?'1.........OF......... N FEE.. .......--- Eftipoott Morkii Tonstrurtion eruti# Permissionis hereby granted..................-- ..... .t .....-------•-•------•---....................................................... to Construct ( �or Repair ( ) an ndividual Sewage Disposal System at No......... am .......... =-•- � • Street - as shown on the application for Disposal Works Construction Pet No..................... Date --_---.__----------__-.----___--_--_-_-___ Boayf/Hea!; h DATE............. ................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Y��tc�►.I lr'WrAll ,� T��t l_�( F=l..o W _ l l C7 +t. S. c '$=:(7 @:,•F.t7. �-r. :,4 `. ^`. 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