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HomeMy WebLinkAbout0153 LONG POND ROAD - Health 153 -Long Pond --R, c)a d Marstons Mills A= 013 - 046 ---- — - - Commonwealth of Massachusetts 013 - dL-I(P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Long Pond Rd Property Address ' Beaudry Trust - Mark E Beaudry Owner Owner's Name information is / required for every Marstons Mills ✓ Ma 4/22/2020 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. Imngoutf:rms A. Inspector Information filling out forams on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. P.O.Box 151 r� Company Address Forestdale Ma 02644 City/Town State Zip Code r � 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4/22/2020 Inspector's Sign re Date The system inspector shall submit copy his inspection report to the Approving Authority(Board of Health or DEP)within 30 day of pleting this inspection. If the system has a design flow of 10,000 gpd or greater, the inspec or and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts jd Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass.gov 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form f' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .< 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts h Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. CitylTown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: no Design on record Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts 9A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �P (ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required fcr every Marstons Mills Ma 4/22/2020 page. Citylrown - State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenancen contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: tank and pit original to house Dbox replaced 2011 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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: 20'+ see asbuilt feet Comments (en condition of joints, venting, evidence of leakage, etc.): no signs of poor venting or leaks t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 h Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2.25'feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal H10 precast tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x5' Sludge depth: 5„ Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? tape and 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.): concrete baffles in place. recommend pumping tank in 1 year 5/2021 under normal use.no major decay present in tank t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �n 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Cityrrown State. Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Dbox is solid no leaks or major decay. no carry overs riser in place Db3 H10 box with 18" ads pipe riser. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �n ,io Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required fcr every Marstons Mills Ma 4/22/2020 Ci /Town State Zip Code D f page., tY p ate o Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leaching is a 6'x6' precast pit with riser in place bottom of pit is 9' below grade. current water level is TT below pit invert pipe. concrete side walls of pit are clean and dry above current water level 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 153 Long Pcnd Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name informatics is required for every Marstons Mills Ma 4/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts (n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 153 Long Pond Rd Property Address Be_a_udry Trust - Mark E Beaudry Owner Owners Name information is required for every Marstons Mills Ma 4/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Deck o 0 3 3 c: c1 0 O J O u O a o c t 62- - ya - a-7' g3 N � t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 Commonwealth of Massachusetts 1� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 5 fe eett Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ® Accessed USGS database-explain: town GIS mapping You must describe how you established the high ground water elevation: lot el. is 100 per gis mapping low in area is el. 50 (long pond) bottom of leaching is el. 91 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C 153 Long Pond Rd Property Address Beaudry Trust - Mark E Beaudry Owner Owner's Name information is required for every Marstons Mills Ma 4/22/2020 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5ins .doc•rev.7/26/ 1 p 20 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I No.��QV 5 ^3;;�S Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for 30im of *pgtem Conotruction Permit Application for a Permit to Construct( )Repair�7) pgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 6 p �j R. `/VIR2.3y1D� YY Assesssoor's�vtap/Parcel I Y i( • ""— �� /d n a 1 i !�s Installer's Name,Address,and Tel.No. `— �'r�!? Designer's Name,4dr9ss and Tel.No. s Type of Buildin Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Natu a of Repairs or 41terati ns A saver when pplicable) A I IV s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Titl of the Environny.4kitayCode and not to place the system in operation until a Certifi- cate of Compliance hasrdn is thl Bo d o l4ea 4 Si Date Application Approved by Date Application Disapproved for the following re sons Permit No. 3 Date Issued:, Fee No. Ves THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 30i - !gat patent Congtructiott Permit 11pplication for Application for a Permit to Construct( . )Repair )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /� Owner's Name,Address and Tel.No.,:O s­ A�sas's'o ap�arNce� N ,�I �. ,1 pQ,SrN> t11 Al AA� rl.. t. Installer's Name,Address,and Tel.No 3 3 v,g �g 6 2^- �'(A Z � Des ner's Name,yddi ss and Tel.No. y /M Type of Buildin Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 1 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design.Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title r Size of Septic Tank Type of S.A.S. ` Description of Soil Nature of Re airs or AlteraH ns(� swer when applicable) yh ��5�2Elfl ^� k 1, 0 �. .� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme taYt ode and not to place the system in operation until a Certifi- cate of Compliance has •eer-iss e '. : t ' d o Si ned i Date Application Approved b Date Application Disapproved for the following reAsons i Permit No. Date Issued ------------------------------------------. THE COMMONWEALTH OF MASSACHUSETTS_ `/ ' BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by r I A -i e gr f CC -x at 1 S -4 1_c h.f n c 14 a ne d has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer (,:; i s_s 1�1�,-. �_r�( r ,- �C�) ,Designer The issuance of this pe rmit shall not be construed as a guarantee that the sys em�will fiidction as designed. Date t i Inspector. No. d � � � Fee THE COMMONWEALTH OF MASSACHUSE l� PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Dizpoe;al *p.5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at ? 1_c: ,09 6 ►njjr and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special condition . Provided: Construction must be completed within three years of th date of this e "t. ` Date: _Approvedby -- ---^-�J 1 ■ S O f] Postage $ g a 3 AEr u7 Certified Fee CO ' ✓ Postmark Return Receipt Fee / M (Endorsement Required) o jot IT 2005 a Restricted Delivery Fee t7 (Endorsement Required) O . p Total Postage&Fees $ US� C� p Sent To lnr s L �r------=-Ta-`-4---- '------------------- Street,Apt.No. or PO Box No. o .7�� � nK-_tree --- ego/ City State,ZIP+4 ew,e pip ���5 Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece o A signature upon delivery f o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Pripri-tj Mail. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811�to the article and add applicable postage to cover the fee.Endorse mailpiece to Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". n If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,May 2000(Reverse) 102595-99-M-2087 / °FIME A Town of Barnstable sT� Regulatory Services 9 Ss' 1659. o 59. Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 July 29, 2005 Mr&Mrs Walter L. Taylor 328 Bank Street#201 Harwich,MA 02645 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 153 Long Pond Road,Marstons Mills,MA was inspected �on June 16, 2005 by Reid C. Ellis a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has"Failed"under guidelines of 1995 TITLE 5 (310 CMR 15.00) DUE TO THE FOLLOWING: Distribution Box is leaking; needs to be replaced with risor. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT COMMONWEALTH OF MASSACHUSETTS w+ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTmENT OF ENviRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ! C i C-n {� Property Address: 153 Long Pond Road,Marston Mills,MA 02648 Owner's Name:Walter L.Taylor and Nancy Taylor w Owner's Address:153 Long Pond Road,Marston WAs,MA 02648 Date of Inspection:6/16/05 Name of Inspector.Reid C.Ellis M Company Name:Ellis Brothers Const.Co. Mailing Address:23 Enterprise Road Yarmouth Port,MA 02675 Telephone Number.SW362-6237 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Tittle 5(310 CMR 15.000} The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority. Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system 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. J Notes and Comments ***,*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 , Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 153 Long Pond Road,Marston Mills 02648 Owner.Walter L.Taylor and Nancy Taylor Date of Inspection:6/16/05 1 Summary: Check , Inspection Samm 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 ava .15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. i Comments: I 1 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. j 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 exfdtmtion or tank failure is imminent.System will pass inspection if jthe 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: �sion of sewage backup or break out or high static water level in the distribution box due to broken or ob ed 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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system w' 1 pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r_ z Page 3 of 11 j OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 153 Long pond Road,Marton Mills,MA Owner:Walter L.Taylor and y Nancy Taylor Date of Inspection:6/16/2005 C. Further Evaluation is Required by the Board of the Conditions exist which require further evaluation I y the Board of Health in order to determine if the system is failing to protect public health,safety or the enviromnei t. 1. System will pass unless Board of Health determ nes in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which wi protect public health,safety and the environment:1 — Cesspool or privy is within 50 feet of a surfs water — Cesspool or privy is within 50 feet of a borde ' g vegetated wetland or a salt marsh 3 f 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 ublic health,safety and environment: _ The system has a septic tank and soil absorp ' n system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface watei 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 deten aine distance **This system passes if the well water analysis,pe formed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates hat the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitro is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysm must be attached to this form. i 3. Other: 3 i s f i I 3 i I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT i S a SUBSURFACE SEWAGE DI SPOSAL SYSTEM INSPECTION FORM I PART A CERTIFICATION(continued) Property Address: 153 Long Pond Road,Marston Mills Owner:Walter L.Taylr and Nancy Taylor Date of Inspection:6/16/2005 D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes N¢ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _/discharge or ponding of effiuent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or spool squid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow aired pumping more than 4 times in the last year NOT due to clogged.or obstructed pipc(s).Number FP(( ' es pumped rtion of the SAS,cesspool or privy is below high ground water elevation. rtion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface a er supply. y Mon of a cesspool or privy is within a Zone 1 of a public well. -VIportion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water i supply well with no acceptable water quality analysis. (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 I 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.] 1 (Yes/No)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 Boards of Health to determine what will be necessary to correct the failure. 1 E. Large systems: j To be considered a large system the system must rve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of th following. (The following criteria apply to large systems in add tion to the criteria above) yes no the system is within 400 feet of a surface d inldng water supply — _ the system is within 200 feet of a tributary o a surface drinking water supply — _ the system is located in a nitrogen sensitiv area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public water supply well If you have answered"yes"to any question m 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. 4 J S Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST I Property Address: 153 Long Pond Road,Marstous Mills,MA Owner.Walter L. Taylor and Nancy Taylor Date of Inspection:6/16/2005 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes N — — Imping information was provided by the owner,occupant;or Board of Health I Were any of the system components pumped out in the previous two weeks? Ylas 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,imcluding the SAS,located on site? _ ere the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the es or tees,material of constriction,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? i The size and location of the Soil Absorption System(SAS)on the site has been determined based on: j Y no — 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 disc jce is unacceptable)P10 CMR 15.302(3)(b)] 5 1 1 i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Pro Address:Property dcess 153 Long Pond Raod,Marstons Mills 02648 Owner:Walter L.Taylor and Nancy Taylor Date of Inspection:6/16/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 t 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):WO Is laundry on a separate sewage system(yes r no>.4V[if yes separate inspection required] Laundry system inspected(yespr no):�00 Seasonal use:(yes or no): -o J Water meter readings,if%vale(last 2 years usage(�)): C7.3 �.r �� 32 tf Sump pump(yes or no): Last date of occupancy: O COM1VIERCIAL/MUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes r no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ��jg/ t Was system pumped as part of the inspection(yes or no): Wo If yes,volume pumped/-c ons—How was pumped determined? ?,-/, ;7E orpumper OF SYSTEM Septic tank,distribution box,soil absorption system —Single cesspool _Overflow cesspool —Priory _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) —Tight tank _Attach a copy of the DEP approval _Other(describe): Appro age of all co n date installed ' kno and source of information ` _ All 00 Were sewage odors detected when arriving at the site(yes or no): Al P 6 s Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) I Property Address: 153 Long Pond Road, Marston Mills,MA 02648 i Owner:Walter L.Taylor and Nancy Taylor Date of Inspection:6/16/2005 • 1 I s BUH DING SEWER(locate on site plan) Depth below grade: 30it Materials of construction: cast iron Z40PVC other( lain): Distance from private water—supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:flocate on site plan) Depth below grade: �-9 Material of construction:�ncrete_metal_fiberglass_polyethylene _other(explain) /1!!t'�If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: Sludge depth: ZO f' Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee r baffle: AP' How were dimensions determined: V Comments(on pumping recommendati ;inlet and outlet tee or a conditioq integrity liquid levels as relat to outlet invert,eviden of lealiage,et ) ' i �V,P ov �� Edo �/ ,;v C�✓ol �H/ 571 T 6�CIIA/.t;t - i GREASE TRAP: / _(locate on site plan) Depth below grade:_ I Material of construction:_concrete metal fibei glass_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 e: Date of last pumping. Comments(on pumping recommendations,inlet and out et tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 153 Long Pond Road,Marston Mills,MA 02648 I Owner:Walter L. Taylor and Nancy Taylor j Date of Inspection:6/16/2005 i TIGHT or HOLDING TANK: tank must be um /V. ( p ped t time of rnspectron)(locate on site plan) Depth below grade: Material of construction concrete metal fiber _polyethylene other(explain): Dimensions: Capacity: Gallons Design Flow: ffal1ons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): ! i ! DISTRIBUTION BOX" (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert /Ism I Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into out of box,etc.): 1 y a J PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition o pumps and appurtenances,etc.): i i ! 1 I ! i I 8 1 4 i 1 i i I I 7 i t Page 9 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 153 Long Pond Road,Marston Mills,MA 02648 Owner:Walter L.Taylor and Nancy Taylor Date of Inspection:6/16/2005 SOIL ABSORPTION SYSTEM(SAS): "ovate on site plan,excavation not required) If SAS not located explain why: i I Type J f � � leaching pits,number_ � �•G%j��/ /^y�/ / --.a���i/ leaching chambers,number: f/ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of pondin g,damp soil,condition.of vegetation, OW A1-0 a 00, CESSPOOLS: (cesspool must be pumped as part f 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 or no): Comments(note condition of soil,signs of hydraulic fai ure,level of ponding,condition of vegetation,etc.): I PRIVY: (locate on site plan) -Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic fail ,level of ponding,condition of vegetation,etc.): 9 I i i I I i f .r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 153 Long Pond Road,Marstons Mills,MA,02648 Owner.Walter L.Taylor and Nancy Taylor Date of Inspection:6/16/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM 274`6 W Provide sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benc Locate all wells within 100 feet.Locate where public water supply enters the building. 0 s 'AAA� I ' d { 12- LIS � � 10 f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: 153 Long Pond,Marston Mils,MA 02648 Owner.Walter I.Taylor and Nancy Taylor Date of Inspection:6/16/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ep ground wate.L feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: bserved site(abutting property/observation hole within 150 feet of SAS) ecked with local Board of Health-explain: o�u� Checked with local excavators,installers:� Z �✓ S Accessed USGS database-explain: You must describe how you established the high ground water elevation: , j 9 � I a(LA 1 11 i f F THE Tpw O Town of Barnstable Regulatory Services MASS. 9�A 1639. ,0�' Thomas F. Geiler,Director rFD MA'S A Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 29, 2005 Mr&Mrs John Beau-dry 38 Wren Lane Marstons Mills,MA 02648 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 153 Long Pond Road,Marstons Mills,MA was inspected on June 16, 2005 by Reid C. Ellis a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has"Failed"under guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: Distribution Box is leaking; needs to be replaced with risor. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder, please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT I I ' COMMONWEALTH OF MASSACHUSETTS 4' Y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a d DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION _ # J, C) Property Address: 929 Old Falmouth Road �^ Marstons Mills MA 02648 Owner's Name: G.Roger Machado 6 — Owner's Address: Same + =' Date of Inspection: July 7,2005 Job#05-198 , r Name of Inspector: PATRICK M. O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. w Y Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: 0ataoOFr►iiiiii X Passes P��N•••°Mgss Conditionally Passes Needs Further Evaluation by the Local A proving Authority AT CK cGn Fa i = rn= ELL "cue Inspector's Signature: iM Date: July 7, 2005e '�i �l��R.T l 1�0.•��O�� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea� S;NSPEG����`�� 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. Notes and Comments: System has three leaching pits,one is full and other two are empty.Tank was pumped as part of inspection, recommend pumping every two to three years. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G.Roger Machado Date of Inspection: July 7,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX 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: 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: 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 distribution box is leveled or replaced ND explain: 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G.Roger Machado Date of Inspection: July 7,2005 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(l)(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. _ 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: Titlo G lncnnntinn Rn—4/1 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G.Roger Machado Date of Inspection: July 7,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— 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 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 forma _No_(Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 11 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. Titia r, inc—flnn P—m 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G. Roger Machado Date of Inspection: July 7,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks '? _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X _ 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: Yes no _X_ Existing information. For example,a plan at the Board of Health. X _ 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(3)(b)] Title G inenantinn P— 411 r,111)00 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G.Roger Machado Date of Inspection: July 7,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—55,000 gal. 2004—62,000 gal.= 160 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped every two years Source of information: Homeowner Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped:_2500_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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Approximate age of system is 25 years old. Were sewage odors detected when arriving at the site(yes or no): No Titia G inenantinn Rnrm 4n e11nnn 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G. Roger Machado Date of Inspection: July 7,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 2' Materials of construction:_X_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Outlet cover under walkway,checked outlet tees from inlet end of tank. Liquid level at bottom of outlet pipe.Recommend pumping every two to three years. GREASE TRAP: No (locate on site plan) Depth below grade:_ 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: Comments(on-pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Titla C Tncnantinn I:nrm 411;11nnn 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G.Roger Machado Date of Inspection: July 7,2005 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): Distribution box under walkway. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Tula C Tnenantinn Rnrm 411 ionnn 8 I Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G.Roger Machado Date of Inspection: July 7,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: Three pits 6 x 6 each 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.): One pit is full to top,one has a small puddle of water in bottom with no recent sidewall stains and third pit is empty with clean sidewalls. i CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): T41A C incnArtinn FnrM 411 Vlnnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G. Roger Machado Date of Inspection: July 7,2005 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. Old Falmouth Road Driveway 31 17 25 20 74 92 1i 103 TiNa C inenan6nn Rnrm 411 v')nnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 929 Old Falmouth Road Marstons Mills MA 02648 Owner: G.Roger Machado Date of Inspection: July 7,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: 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) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 40 and topo map shows property above el.70. Titles C Inenaptinn 17nrm 4/1 c/7000 11 TOWN OF BARNSTABLE LOCATION S 3 Loyt�( ���� ✓LcI SEWAGE # ri•f VILLAGE ASSESSOR'S MAP& LOT •f IN.'$UALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: ,�. - LLden�''COMPLIANCE DATE: Sbd."l!f 631-0, Sl Separation Distance Betweelle 6 Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Stfpply 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 . o 2 �` 3" qg a io LO C,A T ION SEWAGE PERMIT NO. f lid �40 P-0ru VILLAGE � INS�T_ A� LEQlrNAME 6 ADDRESS 1 d U I L D E R OR OWNER "3AOZ IVS'-�q 2C-,' le-5 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ellf/fy �Y. , . 1 � � � . I .� ... ��° Cb L � g c` �� i `� r ,� ,�, , L l THE COMMONWEALTH OF MASSACHUSETTS r i BOAR® OF HEALTH ........... ...........................OF..................... .........-.... Aliji iratitin for R-spogFai ork�vnstrurtivtt �xbti Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at -- - -•----.....--••----------------------------......-------•--- -..... L cation-Address or Lot No. •--- Owner Address Installer Address Type of Building Size Lot.... �29?..Sq. feet Dwelling—No. of Bedrooms___••.......................................Expansion Attic ( ) Garbage Grinder ( ) 44 Other—T e of Buildin aYP g ---------------------------- No. of persons............................ Showers ( ) Cafeteria ( ) d Other fixtures W Design Flow.........����............. �........._gallons per person perday. Total daily flow............ ...............gallons. WSeptic Tank—Liquid capacity/ gallons Length...a.__..... Width....l- .__..___ Diameter________________ Depth...,,,,'.-,-.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_...................sq. ft. Seepage Pit No......./.......... Diameter....1L Depth below inlet._6x..,Qt Total leaching area. ��� 2 Other Distribution box (,�� Dosing to ( ) Percolation Test Results Performed by..__ ...�- � _.V ................. Date..! .?_•-_�.3........ Test Pit No. I.... -_-minutes per inch Depth of Test Pit---/YP.$ .... Depth to grou wat r. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O _ ------•--.-------- ----------------------- •---•------- --•---- Description of Soil �`�' ��__...... �...�.__---���'u----------•--•-------•-----------------------------•----------....-----•----- W x ••--•--•••-•-----------••••••••---•----•••----•••--•----•--•----•-•••--••-------•-••---...••-•--•-••--•-••-•----•••-••---•----••---••---•---•••---•••-•-•-••-•--•...................................... 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 TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasbbeen,issued by the board of health. gn -------- - .. .... - --- - te ApplicationApproved By---- .........••-•--•-•••---••••--••--•-••---------••-----••-•-•-•---------•-•-•••......l ate Application Disapproved for e f o to ing reasons-......................................-•,----------...-------•-------------------•••----•••--•=-•••----......_. -.. Date PermitNo..................................................._.... Issued..................................................... Date Fmsj---`�-.---_'.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... ........................OF _.._.. Appliration for Disposal orksiXomi rnrtiun "ami# R Application is hereby made for a Permit to Construct (Xor Repair ( ) an Individual Sewage Disposal System at.: ✓/ ocationv--Asdr or Lot No. ............ ....._.....---.... -._.,C._it.._..---e_................................. _........ .._......_..........._......... Owner. Address Installer Address Type of Building 2 Size Lot___.,,_"'-fQ!..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building _______________ No. of persons............................ Showers ( ) — Cafeteria ( ) a YP g ------------- P dOther fixtures •---•••-•--------•---••••----------•--••--••--•---•••-•---•----•--•--••--•-•--•---•-••-----••-----••••--•----••••---•••...........................•-• Design Flow___...__..a+�._-g.....________._._____._gallons per person per day. Total daily flow__________ _ _�..............gayns. p q p y __gallons Length_._______. Width.......... Diameter________________ Depth________-. Se tic Tank—Liquid ca acit _ �. F W Disposal Trench—No ____________________ Width______..__._.____._. Total Length_.___.______._.__.__ Total.leaching area....................sq. ft. x . Seepage Pit No-_____1--._--______ Diameter...Z©!--- _ Depth below inlet_�?+__� ____ To 1 lea ing area._�� ....sq. ft. Z Other Distribution box (,, Dosing tank � ,�? Percolation Test Results Performed by.... _ l t_J-1 i�e �� _.___ -ate_�Cr'__ g?1... ,.7� ______.. Test Pit No. 1____Z,r-_._minutes per inch Depth of est Pr l�._.......__ Depth to groufid Ovate/r am.= " _ (X, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil...............` /? �',-" ' e..� - - - -- - - - --- - 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not.to place the system in operation until a Certificate of Compliance has,bee issued by the board of health. xi -------------------------------------------........... --- - -------_----- Application Approved By... .........•-•••-•----••---•..._...-•-.._..••.............................••-•-•--•• ............. Date Application Disapproved for he f l ing reasons----------------•---------------------------------------------------------------------••-•-••-•--..........•••--- ........................................... -----••-• -•----•--•-•--.....•-•-•-..........-•••••---••......••--•-•-------•---------------------•-•-----•-------------•-•------- -•--------•-- Date PermitNo.......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................................................................................. (Intifirab of f 19-amplittnrr IS TO CERTIFY, That the ndivi ual Sewage Disposal System constructed (,--)-Or Repaired ( ) by f __ i'-------------------------------------------------------•••••-•--- ............................................. ..._.._.._ . - -- --- ----=-- Installer at.. .....Ile. has been installed in orda ce with the provisions of T "'IF 5 of State Sanitary , as bed in the application for Dis sal N rks Construction Permit No.. M, -?TZ............ dated- ,---1��.. -•-- THE ISSUAN OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. A DATE------------------•---•-••------•-----.----b••/./. ...f ............ Inspector..........................{lL t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. OF..........................................••----•-••--......•.........._............�y� �� No....................... FEE........................ Di5posa1 jVvrk5 0ono io rrmi# Permission is hereby granted.......... . -.------- O............................................................... to Construct ( ) or�Repair ( ) an Individual Sewage Dispo al System at No...._.._. Street as shown on the application for Disposal Works Construction Permit �No...................../ Dated............................................: f �`- /DATE. Board of Health �� l oe.. ... FORTH 1255 A. M. SULKIN, INC., BOSTON I