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HomeMy WebLinkAbout0108 LAKESIDE DRIVE - Health 108 Lakeside Drive Maistons Mills A= 1020 �} -- - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108•Lakeside Dr. Property Address Oliver Horton Owner Owner's Name information is required for every Marstons Mills MA 02648 10-19-13 page, CityrTown State Zip Code Date of Inspection Inspectlon results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 1lll ``\`��pttnOF 1A///1q��i use only theon the puter, ��� SN glob 1 Inspector ss9 key to move your ` yV( �� cyG cursor.-do not James D.Sears =�: JA M E S m use the,retum Name of inspector sSEARS :y key. CapewideEnterprises,LLC Company Name y,�l'•�RTtf� ���� 153 Commercial St. ��Smt�G�����`• Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number Ucense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Tillie 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-21-13 pectoes 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. I l5ins.113 Title 5 o ial Inspection F Sewage Disposal Syslem•Pape 11 of 17 vim«i i� i t.aoN P•Z r. Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner OwneYs Name is requir reqgonuired a Marstons Mills MA 02648 10-19-13 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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"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): ., tSere•3/13 Title S Official Ins{far$on Font:SLbavfece Sewage DIeposel System•Peae 2 of 17 l-OLA 41 10 1 1.00P p.3 s I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name inforrnation is required for every Marstons Mills MA 02648 10-19-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational_System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines In accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ISins•3113 Title 5 Official Inspection Fcrm:Subsurface Sewage Disposal System•Page 3 of 17 \.l UL L 1 I J 1 I..J.7 i.l p.4 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name ing fired for every Marstons Mills required for eve MA 02646 10-19-13 page. City/Town state 4 Code Date of Inspection B. Certification (oont.) 2. System will fail unless the Board of Health(and Public Water Supplier,If any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in ' is less than 6"below invert or available volume is less than day flow d'�T t6av-3113 ?1Ha 5 Otfidal Ynpeulon Farm:Su6aAaoa Sewage Dfapaael System•Pape 4 of 17 VUL!_�I IJ 1 I.0Vp N.J Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 10B Lakeside Dr. Property Address Oliver Horton Owner Owner's Name intrmrequired tion Marstons Mills MA 02648 10-19-13 required for every page. Uyfrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certtfied 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. ❑ 1Z The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15trt5.3113 TPoe 5 Offidal tnq-Om Fo :Subsvfene Sewage Diapo d System.Page 5 of 17 vct c I to I I:ovp p,o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owners Name informrequired tion Marston Mills MA 02648 10-19-13 required for every page. CttyrTow State Zip Code Date of Inspedion C. Checklist Check K the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health, ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 15ins•3113 Title 5 Official Inspection Fomr Suburlace Sewage Disposal System-Page 5 or 17 V Ia L.,I IJ 1 I.YVfJ r,J./ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr, Property Address Oliver Horton Owner Owner's Name requir d for a Marstons Mills MA 02648 10-19-13 required for every page. Cityfrown State Zip Code Date of Inspedion D. System Information Description: The system is a 1000 Gal. tank D.Box and pit 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2011-39,000Gais 2012-42,000Gal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personstsq.t1., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 01rdel Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 . I vole, 10 i 1.-+Up p,o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Omer Owner's Name information is required for every Marstons Mills MA 02648 10-19-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: 3-23-09 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank.Attach a oopy of the DEP approval. ❑ Other(describe): !Sins•3113 Me 5 Offidw hepedion Form;Subsurface Sewage o#osm System,Page Oaf 17 vvi c 1 1 s i i.•tvp N,y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owners Name information is required for every Marstons Mills MA 02648 10-19-13 • page. Cityrrown State Zip Code Date of Inspedion D. System Information (cons) Approximate age of all components,date installed(if known)and source of information: 1995 Permit # 95-394 Were sewage odors detected when arriving at the site? Q Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: cast iron 40 PV❑ ® C Elother(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 17" 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: 1000 Gal. Precast Sludge depth: 15ins•3113 Title 5 OlGdel Inspection Form:Substa(aoesewage Disposal s slam veoa 9 of 17 Uctz1 IJ 11:4Ip p.lu Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name q eo isreuitedfrev every Marston Mills MA 02648 10-19-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29' Scum thickness 1" Distance from top of scum to top of outlet tee or baffle V. Distance from bottom of scum to bottom of outlet tee or baffle 17' How were dimensions determined? Asbuilt-Tape 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.): Tank at working level. Tank and cover's at 17"below grade. In and out let tees_ No sign of leakage or over loading. 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 t51ns•3.113 _ Title S Of0del hwpecUon Form.Subsur4m Sewage Disposal System•Pape 10 of 17 I V Gl L�1 IJ I I.'fIN p.I I Commonwealth of Massachusetts Title 5 Official Inspection Form UV9m -vim Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name information is required for every Marston Mills MA 02648 10-19-13 page. Citylrown State Zip Code Date of Inspedion D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Mins•3113 Title 5 Official Inspecfion Form:Subsurface Sewage DlsFinal System•Pap 11 of 17 \JGt L I I o 11.4Lp P.IL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr, Property Address Oliver Horton Owner Name information is pugs required for every Marstons Mills MA 02648 page. City/Town 10-19-13 State Zip Code Date of inspection D. System information (Cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, and evidence of leakage into or out of box, etc.): D Box is 12"x 16"-2'below grade. Box is clean and solid Wone line out. No sign of ove loading or solid carry over_ 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. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5irts•3113 Title 5 0MCiG1 ImVec*m Form;Subsurface Sewepe Dlspoael System•Page 12 0117 r <C\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name information is required for every Marstons Mills MA 02648 10-19-13 • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type' ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.): Leaching is a 1000 Gal. Precast pit. Camera out to pit Pit clean, 18"water in pit. No sign of over loading or solid carry over. 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 t5ins•3r13 Tltie 5 offidd inspection Form:SAmm'aos Seweye Disposal system•Page 13 of 17 VCILI IJ 11:4LP P. 14. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name M cited for is every required fo Marstons Mills MA 02648 10-19-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (corn.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soft, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 15ins 3113 Title S OIUciel Inspecdon Form:Subsurface Sewage Disposal System-Page 14 of V -lJ liL 1 IJ 1 1.`t,)p Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm.-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name Inforequired for every is re ry Marstons Mills re MA 02648 10-19-13 page. Cityfrmn State Zip Code Date of Inspedion D. System Information (oont.) 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 3; , 1-1 ��a -� /) -a= 34 � R 08.9 : 17 Fcl� 11,7' g 5/Z 6 ❑ 3 i a 0� 151n3•Y13 The 5 Oftial h syecaon Farrrc SWeurtace Sewage Dlsposei System•PeQe 15 of 17 VCL L I.10 1 1:40P P. Commonwealth of Massachusetts �I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name information required for every Marstons Mills MA 02648 10-19-13 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site (Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells N 6' Estimated depth bFigh ground water: 30+' 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: Dace 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: Abutting property and end of Rd.30+'. Before filing this Inspection Report,please see Report Completeness Checklist on next page. r5ms 3113 Tice 5 Mcial lnspecflon Fomr.Swstrleee sewage CNepoeel system-page 16 or 17 UCI 41 1 o 1 1.1+01) P. p b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Lakeside Dr. Property Address Oliver Horton Owner Owner's Name information is MarStOnS Mills required for every MA 02648 10-19-13 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary:A, B,C. D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file (Sins•X13 True 5 Olffdel fisoerion Form:SuDwrkoe Sewage Disposal System Page 17 of 17 7 Commonwealth of Massa�.t�usetts -c � spy Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Fort dated 61159000.Inspection forms m not be altered to any way A. Certification vfimWn;aut I. Property Information:famon" I GOMPUW,use 9, / e S t -o*fe tab My RqMq to MM YM An caste-do rM uW aye return i 8 n1 I Cky/rbwn state�J zip code Date of inspection: me T 2. Inrr W .—R NO"Inq �.I.v -�� e ilt- Cmnwaptmdrew� �r o 1� J s 0a.!'3- Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the Informp � below is true,accurate and complete as of the time of the Inspection.The Inspection was my training and experience in the PrqW function and maintenance of on site sewage disposal systems.t am a DEP approved system inspector'pursuant to Section 15-M of Title 5 310 CMR 15.000).The system: Fosses ❑ Conditionally Passes ❑ Faits eeds u -Eval n b Local Approving Authority ��jAr s 4yC 0 D 3 The system inspector shag subrrdt copy of this Inspection report to the Approving Authority(8ara; 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 stia submit the report to the appropriate regional office of the DER The orighud should be sent t6 ie system owner and copies sent to the buyer.if applicable.and the approving authority. w>' ""lids only describes Conditions at the time of iron and under tim'catditto of ties at that'ame.This inspection does not address how the system will pm fornn t the futc a under OW same or different conditions of use. mnsp doc•11rMW TWO 5 0MCW heron Formsxwrbw sey„age ohpasel system,- Page 1of16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. CerUff 'on 110 Js 'UP 000 _, � n� .raw or ion inspection Summary:Cheat A.B,C,D or E/always complete all of Section D A) Systems; 1 have not found cayff -- any rnhomnation which indicates that any of the failure criteria described In 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure giteria not evaluated are Indicated below. Comments: �— B) System Conditionally passes: ❑ One or more system components as described In the_Conditional Pass"sectitm need to be replacedor repaired-T�system,upon completion of the replacement or repak as approved by the Board of Health,win pass. Answer yes.no or not determined M N.ND)In the❑for the following statemerits.ff°not determined;please explain. ❑ The septic tank Is metal and over 20 years oki'or the septic tank(whether metal or not)Is structurally unsound,exhibits substanlial irrtilbation or 841tration or tank failure is Imminent System will pass inspection If the existing tank Is replaced with a comptyirng septic tank as approved by the Board of Healh OfmeCompliance tank wig pan won If It Is structurally sound,not leaWV and if a Cer gte cKmg that the tank Is less than 20 years old IS avatiable. NO Expialn: ISUP.doc-!WW4 Tde 5 Onkm hopeamform:aftk.ann" System. Page 2of18 W Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certificate ( nQ 91 Its, Coda .41 /'VJ S 3 iA) oars tie of Insfectim B) System Conditionally Passes(cant.): /►/t1 ❑ Observation of sewage badwp or break out or high static water level In the distribution box due to broken or obstructed pipes)or due to a broken.settled or uneven distribution box.System will pass insi�if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: Al //J ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The ( system vAll pass inspection if(with approval of the Board of Health): ❑ broken pipes)are replaced ❑ obstruction is removed ND Explain: PIA C) Further Evaluation Is Required by the Board of Health: ❑ Conditions exist which require Mrther 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 15.3030)(b)that the system Is not hactloning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh tftV dw-11/2M Title 5 otlrcW hxpectkm Form:subsurtaca sewage vispwd system. Pap 3of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) R L e VD c"Y"Pr { state zip Code ;J -n � 1Q�� Owner's Name Date of IrApection _r A k Further Evaluation is Required by the Board of Health(cont.): 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. Lftsp.doc•11/2004 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Ce�catio�l (Cot,) S, n , y Z � e `� Ei. 141 _ .r off$NOM o D)System Failure Criteria Applicable to All Systems: You must indicate ayes^or"Noll to each of the foilowing for all Inspections: Yes No ❑ eadwp of sewage into facility or system component due to overloaded or dogged SAS or cesspool El due or pondirg of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or croi ❑ Static liquid level In the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ Uquld depth in cesspool is less than li below invert or available volume Is less than i4 day flow ❑ o f Required pumping more than 4 times In the last year NOT due to dogged or obstructed s�Number of times pumped: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ M Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ iAny 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 quay analysis.[This system passes If the well wager analysts,pmformed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds Indicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,provided that no other failure criteria are triggwred.A copy of the analysis must be attached to#&form.] Yes No ❑ The system fatis.I have detemrined that one or more of the above failure Berta exist as described in 310-CMR 15.303,therefore the system falls.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. M13p dw.11iYrJD4 We 5 Oftel lei R me Su�Sewage pisposal Sydw Page 5 of 16 � Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certffication,(oo ) . A e d 0~8 Nam Mft Of m eC&M E) Large Systems: To be considered a large system the system must serve a facility with a �J design flow of 10,000 gpd to 15,000 gpd. - For burgs systems,you must Indicate either''or'W to each of the following,in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface ddWng water supply ❑ ❑ the system Is within 200 feet of a bt ulary to a surface drinldng water.supply ❑ ❑ the system Is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply well If you have answered'yes'to any question In Section E the system Is considered a significant nt threat, or answered W in Section D above the large system has fair.The owner or operator of any large system considered a significant threat under Section E or failed under Seaton D shall upgrade the system In accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department r5�apdoc•1 V� TEE 5 0MCh t hit Foes:ice gySWM• Page 8 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist S�} P try P Zip Code S Name fie of bwoKfim Check if the following have been done.You must indicate W or OrW as to each of the following: YES NO ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ Were any of the system components pumped out In the previous two weeks? ❑ Has the system received normal flows In the previous two week period? ❑ Have large volumes of water been Introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ❑ Was the facility,or dwelling Inspected for signs of sewage back up? J$ ❑ Was the site inspected for signs of break out? of ❑ 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 lurid,depth of sludge and depth of scum? ❑ Was the facMW owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The slam 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)1310 CMR 15.302(3Xb)) MM.doc•1 MAN We 5 MW frapecUon Fomr Subaffi *sewage System Page 7 of m Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System 1 o�m4-2tion state �-- zo coat OwrWs Name Date of hSPWW Residential Fk m Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15203(for example.110 gpd x#of bftiroomO 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 Seasonal use? ❑ Yes tv No Water meter readings,N available(last 2 yews usage(gpd)): Sump pump? ❑ Yes Vito r East date of occupancy. Date CommercialMdustriai Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15203): Galore Per day(lad) Basis of design flow(seats/personsisq R,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,If available: Last date of occ upancyAme: Date Other(describe): t5hap doc•11/2W TWO 5 OffkW Mepecfim Form:Subsrrrlaoe Sewage DIWOW Sysem Page a of to i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System lnfo adon (cont) Ol c�Q ,`s fps W"' /S NA s f 6 yS/J"o 6 e$--�,,1'0!" USl�J 1 CWHwes Name OEM& General tnformablon Pumping Records: Source of formation: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes,volume pumped: gam How was quantity pumped determined? Reason for pumping: :7 Type of Septic tank distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)Cif yes.attach previous Inspection records,if any) ❑ InnovativWAitemative technology.Attach a copy of the c umint operation and maintenance cornbW(to be obtained from system owner) ❑ Tight tank Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all comPormnts,data installed(if bwwn)and source of informa*in: Were sewage odors detected when arriving at the site? ❑ Yes x No ts[nWAoc•11rAW Tdb 5 Oflkhd bunion Form:subauraw&wage Disposal Spbm Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. 77�� m In atio ( t. �� . - -P 7 � ro..,v W;As T7.), stareIrIJA- )owners ame Date of Inspliction `► Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron ' ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: feet Material struction: ncrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: yeam Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) XYes [INo 1 Dimensions: 000 •o�, Sludge depth: 6K&"f f Distance from top of sludge to bottom of outlet tee or baffle :3 e-Z Scum thickness o2 Distance from top of scum to top of outlet tee or baffle CA Distance from bottom of scum to bottom of outlet tee or baffle �wd. How were dimensions determined? i1 t5insp.doc-11=04 We 5 Ofruaal Inspedton Form:Subsudace Sewage Disposal System- Page 10 of 16 1 i Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) l ZIP el�js L oar of dupedbn 2— Comments(on pumping recommendations.inlet and outlet tee or baffle condition,structural Integrity. liquid levels as related to outlet Invert.evidence of leakage'etc.r Grease T (locate on site plan): �`� Depth below grade. fed Material of construction: 0 concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tree or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations,filet and outlet tee or baffle condition,structural NO". liquid levels as related to outlet Invert.evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan). Depth below grade_ Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(e)plain): tSMsp doc•112004 TWO 5 offiM Foam:soudwe Sewsge DWOSd syrstern Page 11 of 16 Commonwealth of Massachusetts J Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Inforjnaflon (cons) 0 k Ae d e kn -e o llq sFll �-�ff ��16 ZIP ter- i v OwnereNaffe Vtare Tight or Holding Tank(cont) Dimensions: Capacity: ! aftm Design Flow: tad y 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.): Distribution Box(if present must be opened)(locate on ibe plan): Depth of quid level above outlet invert ® / Comments(note if box Is level and distribution to outlets equal,arty evidence of solids carryover,any evkiencs of leakage into or out of box,etc.r q Pump Chamber poc ate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Wkisp.doc•110Q4 We 5 O1ftW Inspection Form:Submufam Swale DiapWd System• Pape 12 of 16 C Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Sy em of (con .)r,on ed e Z Code ,4ddress /o ip OwWsName Date WMPIMM Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Z�14 Soil Absorption ( System(SAS)(locate on site plan,excavation not required): Y If SAS not located,explain why: Type: leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. f ❑ innovativelaltemative system /) , Type/name of technology-. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): r Ji r� v s2� t5insp.doc•11/2004 Title 5 0MCW Inspec ion Form:Subsurface Sewage D"imposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments '�V- u Subsurface Sewage Disposal System Form C. Sy§tem Info #i n (co ) lr p •'I c� Ms c n state ap Gwe (J dJv.) �Jz.� �ylter X? 4'- ers Name Date of kfipection 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.): Privy(locate on site plan): r ' —Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): tsimp doc-11/2004 Title 5 official inspection Form:subsurface Sew age Disposal system Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Sy f io )s31 /,,)��e , v eA r 7 M 7 75 Owners Name Date of I Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system including ties to at feast two permanent reference landmarks or benchmarks.locate all wells within 100 feet. Locate where public water supply enters the building. ----Y1 _ PW L&� � � J) 9 A ad 1� 1 �c B19 a� r�- t5msp.doc•1112004 TMe 5 offidal kispec Lion Forth:Subsurface Sewage Disposal System Page 15 of 16 'I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.14( r L Address 1 S ZipCode owners Name Date or lagpectlon 7 Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water. Please indicate all methods used to determine the high ground water elevation: ILd� Obtained from system design plans on record r If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within ISO feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You st describe-bow fiesta ' hed the igh grounrater elation: d-DAR�v lr4 tSinsp.doc•1112004 Me 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN OF BARNSTABLE LOCATION SOB ���� tbgUr "SEWAGE# Qjr . �J9 VILLAGE + M\ws, ASSESSOR'S MAP Q LOTIOV—,017 INSTALLER'S NAME & PHONE NO. SEPTIC TANK C4PACITY\' LEACHING FACILITY:(type) (. (size) NO. OF BEDROOMS c� PRIVATE WELL OR PgB -11� WA'rFR BUILDER OR OWNER Mos. DATE PERMIT ISSUED: '• DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes ' No 1i pp i TOWN OF BARNSTABLE LOCATION SEWAGE # " VILLAGE ASSESSOR'S MAP & LOT/0-V-6/7 INSTALLER'S NAME & PHONE SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (. (size) f 000 NO. OF BEDROOMS PRIVATE WELL OR PURUC WATER BUILDER OR OWNER fn S' DATE PERMIT ISSUED: �� • DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No m gK E7 cc�� ASSESSORS MA P NO:__ _7 �V/ qq No... 5---.1Y. 9 PARCEL NO: FI&s....3.- 4� ........---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diri.pootal Works Toaaotrurtion 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( Vran Individual Sewage Disposal System at:. .....� ...... . \� ..................... .......................� ------------------------------------------------------------------------ rit�on-:\i Irc - ...►.� or Lot No. .............. ---- -..... O cr Addre �............. a `(�(l cam' M LU :..ICI Installer v v , A�dress d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms------------------------------ - - -Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons:........................... Showers ( ) — Cafeteria ( ) Qt Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width-------......... Diameter---............. Depth................. x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter....--.............. Depth below inlet.........--......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date..---...---------.................--.... aTest Pit No. I................minutes per inch Depth of Test Pit._.-----_--.------ Depth to ground water.....:.................. Li, Test Pit No. 2................minutes per inch Depth of Test Pit.-.-----.----------. Depth to ground water.....................--. 0 Description of Soil..............................................................................................................................,......................................... V - ..........••-•--•-----------••------•--------------------------------••--•-•--•••-•--•........----•------••-------••-•..-------•-----------••-•---•-•-------•-------•..........._......--•--------...... W ----------•--•-•------------ -------------•---•---------------...--------------------- •----------------............- -------------- Nature of a aI s or A to ions—Answer l�en applicable_!' --..-._.�. .._ �X ll ..--•--.......--•------------------------------------------------------------------••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compli h s been ikinedby the board of health. 22 Signed ........ CO cJ ..1. . .Q.��:...... Da Application Approved By ........ ... ... 1-- --------- ---- ------------------------ `ate..-. Date Application Disapproved for the following rearons: . ............................................... . ............................ .................. .. ................... .......................................................... .................. ........................... ....................... ......................................--. . ........ ........................................ c� 1-111te Permit No. ......... �r" . / ................ Issued ...........3-..—J.�p.-- -?.—5 ............ ce ric - s+.e -✓ 1�._,..�..,.r...-.;.�..- ...� yy,,,..w.f,.e.:i,y3r.....:.,.,-...........�� :....la.w,.-,;--......:.-.`...:a1.-+..J":..Nl�•f.1,:i.�..�t'4".......r^".{jyl_"t.-,r_'v"v'�+.�^`^b �. trrif;.v:.f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN-OF BARNSTABLE App iratinn for Diripoml Works Tunutrnr#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( 1�an Individual Sewage Disposal System at: .A. ��S-------------------------------------------------------------------------------- oca6011-:lddre or Lot No. ---------------�a----!".Oc---..---•- .....---.....------. ��m .. --- --------------------------- ------------- --- ------ --- Orcner Address a \ ........_ '� .c - ----••-••-•--- ---- (1 crry LW---- ""------------- Installer ... Installer Address UType of Building Size Lot............................Sq. feet _ Dwelling—No. of Bedrooms...............�___-______.._-___.._.__Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—Type of Building No. of persons............................ Showers g ---------------------------• P ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------ -----._.__...-------------------------- -•.....-••----•--•-•••-•--•••-.....-•---•..............•----- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_____.__---gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................................... ..................................... Date........................................ Test Pit No. I....::':�minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch"Depth-of-Test.Pit_________.......__T Depth to ground water........................ P4 --------------------------------------------------•-----------•-••-----.................---•.••••.......................................................... 0 Description of Soil..........z.....--- `............. ............'•------•-----•--••-------------...----------•--------------••----------------••-------- W x - - U Nature of Repairs or Alter ions—Answer when applicable —k- ___.__1.0(ib _.._.A. cy.t .; l i d --------------•-----------------------------------------.••.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of-the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certific e of Compliach s been` the board of health. /- Signed .... .. � _ .... ...................................... ��...16.�4��:...... Application Approved By ..............D_R__t__3..-'3�....A.r�� . ',� 3-462.....?-5-.. Dwe Application Disapproved for the following reasons: ................................ .................................... ................................ ....................... ........................ .................................................... . ............................................................................................................ ........................................ X Q 'Pere Permit No. ..-----�-- -` -t -5y------------------- Issued ...........��...-�f f 5. ^_9"—--- ———`—vJ+"++'uu'o— ——_Q++'_m_ —e THE COMMONWEALTH OF MASSACHUSETTS __.�......_,,. .��..,�,Q�_,. BOARD OF HEALTH TOWN OF BARNSTABLE CZer#ifi ate of Comlalianre THI ,IDS TO CER II ,Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �) Y - —. tJ.J - Insrdlcr Mat .-..._.............���.................��. 1L ..-.. 4 _ '----------------V)..'.�..-1..1 v.. ............................................ . has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as desgsibed in the application for Disposal Works Construction Permit No. --------- dated .. / _Q .-.--....._._. 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 �j TOWN OF BARNSTABLE No...... / t�` y FEE... <.. --....:. ••-•-- �is�nsttl nr� C�nnutriirtinn �rrmit Permission is hereby granted-------ZZV---------- ....................................... to Construct ( ) or Repair an Individual Suva e Disposal System at NoC �—�(�ti�iC � Mr�nt �- -.__._ !--K-�:- ------- �_(Yl 1L-Lam.... Street _ n as shown on the application for Disposal Works Construction Permit No.-��:_=��ryDated.�,_���`f�• .............................. = ---------------------------•-------... Board of Health DATE.............. ........................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS LOCATION SEWAGE PERMIT NO. if0 - l �E l.� s I o 2 " ®j 7 VILLAGE WlAr INSTALLER'S NAME AND ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � • ! , � �' ,. m� o � �� �3 �.� � . .� ��-� � d BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair an -Individual Sewage Disposal System at: qmner Address Installer Address Z Other Distribution box ( ) , Dosing tank ( ) � THE COMMONWEALTH OF MASSACHUSETTS Description of �� Nature o R�^ " "^ Alterations—���� �"= �p�^�= '—'—_--_--_..-_'.—_.—'_'--------_--'---.___-'--_.-'_---_...--_—'-'C)--_--.-'----_____— Agrceuzcoz: The undersigned agrees to instal{ the aforedescribed Individual Sewage Disposal System in accordance with � the provisions of TAIT�11 5 of the State Sanitary Code »�oo6 further a rees not to place the system in operation until a Certificate of Compliance has been issued by the boar 5 boa rtr _ X/ Date Application reasons:-------.---'---_---_-_--..---_----------.----------'- _------------�_.-"��_--------__------'--'_---'--'-_------------_.-----.---_----_-----.---'------ Date � Date � L Nf_..l.:J [... ... FEB..... ^ .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................... ...............OF........................................................................................... ApplirFatiun for DiipouFal Worka Tunitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at: .................. ..... ... sr+�......... ...... ..... - .. - ................ �- /�G�(C L ion-Address or Lot No. -- f/....... ..... . .......-•-•......--'........................... ••--•................••----._...........-• ---••----•'-•................................. ..... ner Address .�7. ............................................... .................--.._....... ---------•--•---....-•-....--•-------- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------------------•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.............._..._. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x .................•---------- --.........-••'-•--••-'-'•-•'•'••-•-•-•-'-•'.......•-••-.....-•.._._............._....._...--"-•'•--._.........••"-•--•-. 0 Description of Soil........................................................................................................................................................................ V ••••-'•-----••--'•••---'•••-•---•-•-•••-'•'-••-'•.......••••-•••'-'•••••----•--•-•••---•---••-•'--••------'-•-••-•-•••••"•----•'-----•-••-'•--•-'................................ W •---•-•--•-•....................••-...••••--••----•----------•-----•••--••--------•--•............••. --•-.._ U Nature of Repairs or Alterations—Answer when applicable_ ___ .............. . .d. - ---------------------•-- ---------j--•--•-••----.....----•••--'•.....--•-----••'•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT?,;�. 5 of the State Sanitary.Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by th�oar Signed--. K ... • • '•"• ... 00 Application Approved . •. C. = = f )-4/...-...... Date Application Di s prov f or t f ollowing reasons--------------------------•-••----•----------•------------------••-------'------------------•-......•............ ......................... ... .... -•-••--•'----•----'-•••--••••-••.....•""•'--•-'•-•-'_......._..•••.._.......-•'•--•'--••-------•-•-••-•--•-••-•--•'--•-•---------••-•-----•--••---...._.... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of Toutpliatta T� i IS TO Lat the Individual Sewage Disposal System constructed ( ) or Repaired j ) by-- /. / (er at...... ... . ... . ......................................�e . .......& application for Disposal Works Construction Permit �o.... r ° he State Sanitary Co e 4XI scribed i-- the /�hPP been installed In accordance with the rovtsions of TI'� ��� dated_.. ._. ___-----___---________ THE .ISSUANCE OF HIS CERTIFICATE SHALL NOT BE N UED AS GUARANTEE THAT THE ,_ SYSTEIoeI' WILL FUPICT N TIS-FACTORY. DATE............. • C�........---•--•--'--.....•... Ins l " THE COMMONWEALTH O SACHUSETTS BOA OF H . OF. :......: :. ......- .... No../':�� ....... FEE. .... ttP �io�ro ZagD' ermission is hereby granted... . _�"y.to Construct ( ) or ep it �(") an dividualat No.--•••-�©'•' -.. . .....-' -----•-•'-• �... . •. ................ ,f ..................Street as shown on the appli tion for Disposal Works Construction P in* I ___` .....f-�_ Dated " /.............. y' -Vo101e 1 Board of Health DATE.t FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS