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HomeMy WebLinkAbout0089 LITTLE NECK WAY - Health 89 Little Neck Way Marstons Mills A= 076- 057 . - - J I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M -76 P-57 Property Address Francis Budryk Owner Owner's Name information is MA 02719 February 28, 2012 required for every 1 Main Street, Fairhaven page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms Y . on the computer,use only the tab 1. Inspector: O —4 b I key to move your cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections my Company Name 19 Hummel Drive Company Address fen South Dennis MA 02660 Cityfrown State Zip Code (508)385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addresstand thate �n information reported below is true, accurate and complete as of the time of the inspection. ThVnspep was performed based on my training and experience in the proper function and matn}enance of}on sg sewage disposal systems. I am a DEP approved system inspector pursuant to S4ction 16-340 o-n Title 5(310 CMR 16.000).The system: t ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r February 28, 2012 Inspedor'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 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. t5ins•11/10 Title 5 Official Ins on Fo ub ace Sewage Disposal stun• ge 1 of 17 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owner's Name information is every 1 Main Street Fairhavenrequired MA 02719 February 28, 2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 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 ears old is available. P 9 Y ❑ Y ❑ N ❑ !ND(Explain below): N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owners Name information is MA 02719 February 28, 2012 required for every 1 Main Street, Fairhaven page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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): N/A ❑ 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): N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M -76 P-57 Property Address Francis Budryk Owner Owner's Name information is required for every 1 Main Street, Fairhaven MA 02719 February 28, 2012 page. CiI rrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °l 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner owner's Name information is MA 02719 February 28, 2012 required for every 1 Main Street, Fairhaven State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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. t5ins.11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owner's Name information is required for every 1 Main Street Fairhaven MA 02719 February 28, 2012 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owner's Name informaticn is MA 02719 February 28, 2012 required for every 1 Main Street, Fairhaven page. Citylrown State Zip Code Date of Inspection D. System Information Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 11=32,000 gals. 10=28,000 gals. Detail: Sump pump? ❑ Yes ® No occupied Last date of occupancy: Date Commerciallindustrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No N/A Water meter readings, if available: t5ins•111104 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts uOW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 ,p Property Address Francis Budryk Owner Owner's Name information is required for every 1 Main Street, Fairhaven MA 02719 February 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: No pumping info was available. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest .inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address lug Francis Budryk Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 February 28, 2012 required for every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank, d box&leaching were installed on 1/16/79 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑cast iron' ®40 PVC ❑other(explain): Distance from private water supply well or suction line: N/Afeet Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): 3'with riser to 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 5'X9'X6' 1000 gallon Dimensions: 4" Sludge depth: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title t e 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owners Name information is required for every 1 Main Street Fairhaven MA 02719 February 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 21 811 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Thin layer Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete outlet tee was present. No inlet tee. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Traplocate on site plan): ( P ) Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M -76 P-57 Property Address Francis Budryk Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 February 28, 2012 required for every aven ry page. CitytTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/A 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.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts c usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owner's Name information is required for every 1 Main Street Fairhaven MA 02719 February 28, 2012 page. Citylrown 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 level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order. 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.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 February 28, 2012 required for every page. City/Town State Zip Code Date of inspection D. System Information (cont.) Type: 1-5'x6'pit ® leaching pits number: w/1'stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was found with 2' of water present with a visible stain line approx. 14" below inlet. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•1 Ill 0 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owner's Name information is required for every 1 Main Street, Fairhaven MA 02719 February 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions " N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner owner's Name information is required for every 1 Main Street, Fairhaven MA 02719 February 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3? 16r' , Z 'v 3 YL 38 ` L � t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owner's Name information is required for every 1 Main Street, Fairhaven MA 02719 February 28, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 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. Date 78 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: MIW 29 Zone C 7.9' 2.9' adjustment You must describe how you established the high ground water elevation: Soil was sandy. USGS groundwater map for Barnstable showed ground water at property to be approx. 56.4'. Groundwater adjustment in area at the time of inspection was 2.9'. Bottom of leaching that was dry at 107 was found not to be located in the high groundwater elevation at the time of inspection. Test hole on plan also showed no water found. A minimum 30' separation from the high groundwater level was present. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y< 89 Little Neck Way, Marstons Mills M-76 P-57 Property Address Francis Budryk Owner Owner's Name information is required for every 1 Main Street, Fairhaven MA 02719 February 28, 2012 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -)6 Commonwealth of Massachusetts _ 57 Title 5 Official Inspection Form Substurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Little_Neckay,W Marstons Mills Property Address — — — - - -------- -- Francis Budr kk Owner Owner's Name — — information is required for every -1 Main Street, Fairhaven MA 02719 Au ust 12—=-- 2009 ------------------------- — — --�-- page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information on the computer, use only the tab COPY key to move your 1. Inspector: cursor-do not: f use the return Trot Williams— —_— ---- —-,- --- ---- — -- --- key. Name of Inspector Troy Williams Septic Inspections Company Name 19 Hummel Drive Company Address B(ItlR South Dennis __ MA - 02660 _ City/Town State Zip Code (508) 385-1300 S1682 Telephone Number License Number B. Certification I certify that l 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 Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ NF:a'Is *m q t ❑ Needs Further Evaluation by the Local Approving Authority J' -n tu....f n " Az� Au ust 12 2009 -1 rt� "�i Inspector's Signatufe Date N The system inspector shall submit a copy of this inspection report to the Approving AuthWity (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. Lj 89 Little Neck Way,Marstons Mills•03108 Title 5 Official Inspection Form:Subsurface Se ge Disposa Syslem lage 1 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Little Neck_Way, Marstons_Mills Property Address Francis Budryk Owner Owner's Name ----- -------- —— ---------- information is 1 Main Street, Fairhaven MA 02719 August 12, 2009 required for every � page. Cityfrown State. Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria.not evaluated are indicated below. Comments: System meets minimum standards set by Mass DEP at the time of inspection only. This inspection is not a guarantee or_warranty on the future working conditions of leaching, pies or components_ B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: N/A ❑ 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 obstruction is removed 89 Little Meck Way,Mardis Mills•WKS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 89 Little Neck Way,_Marstons Mills Property Address i Francis Budrryk Owner Owner's Name --- -------- ----- --- -- -- -- — — information is required for every 1 Main g _Street, Fairhaven MA 02719 August 12--'—2009 ------ ------------- - - - - -- -- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: N/A ❑ 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 ❑ obstruction is removed ND Explain: N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.3O3(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 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. 89 Little Deck Way,Marstons Mills•03108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Little Neck Way,_Marstons Mills Property Address Francis Budyk Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 August 12, 2009 required for every _ _ —g _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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: N/A *` This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. N/A D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No .. ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool - ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 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 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. 89 Lillie Neck Way,Marslons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�' 89 Little Neck Way, Marstons Mills Property Address Francis Budr)k____ Owne Owner's Name required fo is 1 Main Street, Fairhaven MA 02719 August 12, 2009 required for every — _ — _� page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of.a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® Any portion of a cesspool or privy is less than 1.00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to.this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® 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. 89 Little Neck Way,Marstons Mills•03r08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal Systein r Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .° 89 Little Neck Way, Marstons Mills Property Address Francis Budryk _ Owner Owners Name information is required for every 1 Main Street, Fairhaven MA 02719 August 12, 2009 — _—_ .—_ — — _�_ page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate'yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a.plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 89 Little Neck Way,Marslons Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systerp•Page 6 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills Property Address �---__—_ -- --- Francis Budryk _ Owner Owner's Name information is requires for every 1 Main Street, Fairhaven MA 02719 August 12, 2009 -- — page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330gp Number of current residents: , 01 f 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 ❑ No Water meter readings, if available last 2 ears usage d 08=20,000gals 9 ( Y 9 (gpd)): 07=25,000gals Sump pump? ❑ Yes 0 No Last date of occupancy: Occasional use Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A _ _ Design flow(based on 310 CMR 15.203): N/A Gauons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NIA 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: N/A Last date of occupancy/use: N/A Date Other(describe): N/A 89 Little!Neck Way,Marstons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 89 Little Neck Way, Marstons Mills Property Address Francis Budryk Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 August 12, 2009 required for every —9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No pumping info available Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A _ — - gallons How was quantity pumped determined? N/A - Reason for pumping: NIA _ Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Tank,d-box & leaching were installed on 1/16/79 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No 89 Little Neck Way,Marstons Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 89 Little Neck Way, Marstons Mills Property Address Francis Budryk Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 August 12, 2009 required for every _ _--__.— _-- �_ page. Cityrrown State Zip Code Date of Inspection ' D. System Information.(cont.) Building Sewer(locate on site plan): Depth below grade: -18"+ - feet Material of construction: ❑-cast iron ® 40 PVC ❑ other(explain): - Distance from private water supply well or suction line: N/A _ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection.- Septic Tank (locate on site plan): 3' with riser to 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'X.9' X 6' 1000 gallon " Sludge depth: 6 1- — Distance from top of sludge to bottom of outlet tee or baffle 2 6 Scum thickness none Distance from top of scum to top of outlet tee or baffle 6 — - Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Probe/Measured 89 Little Neck Way,Marstons Mills•03/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Little Neck Way_Marstons Mills Property Address Francis Budryk _ Owner -- ------------------------------------------..--------- Owner's Name information is 1 Main Street, Fairhaven MA 02719 Au ust 12, 2009 required for every _ __-- _� page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence,of leakage, etc.): Concrete outlet tee was present. No inlet tee. No evidence of leakage or damage was found. Tank was not in need of pumping,at this time. Grease Trap (locate on site plan): Depth. below grade: N/A _ _ — feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A _ Scum thickness _N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle. N/A Date of last pumping: 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.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A 89 Little Neck Way,Marstons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i Commonwealth of Massachusetts P. Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments < 89 Little Neck Way, Marstons Mills Property Address Francis Budr ryk _ Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 Au gust 12, 2009 requirec for every _--.. __ _.__ ___ _� page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: N/A Capacity: N/A - -- --- gallons N/A Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A-- ----- Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A — Date Comments (condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found in working order with good flow through to leach pit.. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No 89 Little Neck Way,Marstons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills Property Address Francis Budryk Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 August 12, 2009 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A Type: � ® leaching pits number: 1-5'x6'pit w/1'stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of.soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil was sandy. Leach pit was found dry with a light visible stain line approx. 14" below inlet invert. No evidence of hydraulic failure or problems in the past were found at the time of inspection. 89tLittle Neck Way,Marstons Mills•03f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form = Not for Voluntary Assessments 89 Little Neck Way, Marstons Mills Property Address Francis Budryk Owner Owner's Name requiredfo is 1 Main Street, Fairhaven MA 02719 August 12, 2009 required for every _ g_ _ page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan).- Number and configuration N/A Depth —top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A- Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure,,level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A_ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A 891116 Neck Way,Marstons Mills•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Little Neck W_ ay,_Marstons Mills Property Address _ — Francis Budryk _ Owner Owner's Name information is 1 Main Street, Fairhaven MA _02719 August 12, 2009 required for every . _---_ __ _ _ � page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. it tV.!wk'w..✓ � 6 t. 3y r ' Z ' L+ : 5 `� ; 38 3 o 89 Lillie Neck Way,Marslons Mills•03/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments kM 89 Little Neck Way, Marstons Mills _ Property Address Francis Budryk __ Owner Owner's Name information is 1 Main Street, Fairhaven MA 02719 August 12, 2009 required for every _9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water. Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: 11/13/78 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: MIW 29 Zone C 8.1' 3.2'adjustment__ ____ _ You must describe how you established the high ground water elevation: Soil was sandy. USGS groundwater map for Barnstable showed groundwater at property to be approx. 56.4'. Groundwater adjustment in area at the time of inspection was 3.2'. Bottom of leaching that was dry at 107 was found not to be located in the high groundwater elevation at the time of inspection. Test hole on plan also showed no water found. A minimum 30' separation from the high -groundwater level was rp esent. 89 Little Neck Way,Marstons Mills•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 LOIrArl0ld S E G E PER#)�" -�� � N0. ; VILLAGE / INS TA L ER'S NAME & ADDRESS I 6U11DER OR OWNER D E ATE P RINIT ISSUE D DAT -E C 0 M P L I A N C E ISSUED i .71 I r � . i V" JJJ a✓ /� I i I TOWN OF BARNSTABLE LOCATIONWL--ti SEWAGE # s� y� VILhAGE ASSESSOR'S MAP & LOT 76` S INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f�o o zi a�ah LEACHING FACILITY: (type) �,' (size) S xG ` � s�'i�► NO. OF BEDROOMS BUILDER OR OWNER �� U d ✓� PERMITDATE: COMPLIANCE DATE: / L 7`� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility •3V'd-- 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-- A fZ 5 2 - 251 C� 38 i F No.E�E t � L • CA�T1•1 WAG SE VII-.LADE / /0/6- INS TA L ER'S NAME & ADDRESS r/6e,C;r 6764C C6 B U I-L D E R OR OWNER DATE PERMIT ISSUED v DATE COMPLIANCE ISSUED Y'( 3� � { ::Q . �� .4 �F ��;��� 1 �. �;; . - .- � �, �,� � ��� �� ,� .�/ �9�� �,�,o�� -d.s � _ , ,�c�Ar g'z No............�.�.... i FRa............................ THE COMMONWEALTH OF MASSACHUSETTS F HEALTH --... . Appliratiou for Dispaa al Works (funstrurtiun rrrmit Application is hereby made for a Permit to Construct ( " or Repair ( ) an Individual Sewage Disposal System at: ....LX M:-- �.......Zt ' ,�., &S..../ �L "....._...... =� t •..................... .. �- - _ Location-Address_ Owner Address a .............................................................. Installer Address _ U Type of Building Size Lot.. >_. = .Sq. feet Dwelling—No. of Bedrooms..............._ ...._....._..._.........Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—Type of Building No. of persons ....................... Showers yP g ---------------•--...---•-•- P (�) — Cafeteria ( ) dOther fixtures ._..-F....-•-•-------------------------------------•------•--------------•--------- W Design Flow.114 Y.a.... ...,33_ ..gallons per person per da,y. Total daj�yffiow------- �a ....................gal�lo>p. WSeptic Tank—Liquid capacity.Z Q.gallons Length.......... Width................ Diameter----.........--. Depth.... x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No...-.4-.1r-.-ff.. Diameter.................... Depth below inlet_----........... Total leaching area..................sq. ft. Z Other Distribution box (k ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......---.............. fx, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 94• ........... •-••................................•-•---••---••---------••-•-----.........-••-•---..........••-•--•_-•---- O Description of Soil..................... C��UfU x �Ol�kt -----_-•--_---- -----------------------------------------••-•-----_-_-•-------------------------------------------- V ..................•-•--....-•••---•---•-•---•---------•----•----•-••-•--•-•••-•-----..f-_-- e........................................ 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 1.;=. 5 of the State Sanit Co e—The and • ed f r agrees not to place the system in operation until a Certificate of Compliance h been ssued by t boa iealt Sed..... .. .. - .. ............. ................... ��-��...f .. e Application Approved By........... Date Application Disapproved for the((//ollowing/reasons-.............................................---------------•--------------•---------••--.............-----.._ -----•-•-----•----...--•-----•••-.-----------••...............••--------•-•-•...---. ----•---••••--------•-••............•-• .............. Permit No...... ...................................... Issued___ .... ....................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ewe` ....................................:.....OF..........0�3�tlsJI........................................................... %.Urrfif iratr of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( ) by..............Xo..6Zrh.T_-............ ....................................................................................................................................... Itistaller /6� / GGUG TILL at .......... ` ............................... '.....................................................................................-...... has been installed in accordancevith the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... 1. .................... da.ted-__..--/I,/-n/V---7 ................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE... ...-,- •-� _. 2 ....................................... Inspector...... ............... No..%�..✓�..._.. Fizz............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................."I......O F....................................... Appliratinn for Disposal Works Tonstrnr#inn Upprmit Application is hereby made for a Permit to Construct V-)"'or Repair ( ) an Individual Sewage Disposal System at: ' . Jy:..�.,t.,J�...sty.�,�ll.-_....4(�.(1. ......AP41L aINS....�'.1.z«-5...................A��................................... - Location-Address .....sr Lot ..,o:�.'�yrEr���c�Ef�l�s Owner a - Address W � q}•' GD-Ldl ?V-�=------- .................................... Installer Address Type of Building Size Lot:_o 2_Z....Sq. feet -� Dwelling—No. of Bedrooms...........:3...........................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building ............... No. of persons............................ Showers —Type g ------------------•------•-•---------...---P � ) — Cafeteria ( ) d Other fixtures ................... ........._. ... W Design Flory// ,�_?____.T... J. 1.--_.gallons per person per day. Total Sia�y flow----��-Y ...........................gallons. WSeptic Tank—Liquid capaci�yO.oA-....gallons Length..... ::_._____ Width..(............. Diameter................ Depth. _........... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No... :__ 1... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by-•--•••-•••-•-•---••.............•---.......----•-----••-•------......._. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch, Depth of Test Pit.................... Depth to ground water........................ 9 ,f r� !• r •---•-......--•`----•--•........................•--.....-----......---•--.......----------.......-------•--•---•---...............--....--•-- I I O Description of Soil. ..... l......--`---......•-•-!''----......••-----••-••-•••--•--•----------------••-•-----•--••.....---•-••....•••...................... 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 L IT I.;.,. 5 of the State Sanitary-Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h� been/issued by tVelb0a�� iiealt Signe � ._......__ Application Approved By................ •-------------------•------.......-------••----•---.............----.........-- ........................................ Date Application Disapproved for the f/ ollowiny reasons:------•-----------------------------•---.....-•-----•----------------------....-------------•--•------•----.-. Date PermitNo......................................................... Issued.......................................-------------•-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........I..............................OF.............................................................. (9rdifirttte of TontpliFanrr THIS IS TO�CERTIFY,LThat,,,`the Individual Sewage Disposal System constructed ( )' or Repaired ( ) by................................--•-...•-••--........-•---............................----•-----•----••-------......----•-•••-----------------•...._......------........-----•----••---•----......._ t"l Installer at.........................................................l --------------------------------•------------------•---••------------.....-------------•------ has been installed in accordance with the provisions of TITLE// 5 of The State Sanitary Code as'edescribed 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. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD/OF . HEALTH x�ti ...........................................OF..................................................................................... No......................... FEE........................ Disposal Works Tonn#rurtion rnmit Permission<is hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an,Individual Sewage Disposal System atNo............................................................................................................................ Street as shown on the application for Disposal Works Construction Perm' No.... ............. 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