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0112 MISTIC DRIVE - Health
112 Mistic Drive Marstons.Mills.. P i — - A = 079 041 i i i i I i I I i TOWN OF BARNSTABLE LOCATION SEWAGE # VELLAGE Y,5, e!90 S,J* ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)AX"7- (size) NO. OF BEDROOMS 4 BUILDER OR OWNERZw&ze—,01 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and L aching Facility(If any w lands exist within 3 v feet c cility) Feet Furnished y L F�2 6ti1� S�� fir. , yVlacs�ns �I;IIS r V to �^ 1 � r /4 �c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Mistic Drive ......,........._............. __._.._:..... _ _._. ----........... .....- .... .__....m......_.__ Property.Address David Chernov Owner Owner's Name information is MArstons Mills Ma 02648 _ 8/20120/4 required for every — _ __.._ ___..._._.._____.._.. _._...__� page. City/Town. State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may riot be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 2 on the computer, J use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones usethe return — ......:...:.... -----......_.__ __._............_. _.................._---:._—:___._............ key. Marne of Inspector Capewide Enterprises r� Company Name 153 Commercial St. Mash pee_ Ma 02649. Cityrrown State Zip Code 508-477=8877 SI 4522. Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at.this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was perfor ned 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: ® Passes ❑ Conditionally passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/20/2014 _ �._._..........._.m._.._._..---....__..__....... 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. ****This report only.describes conditions at the time of inspection and under the conditions of use atthat time.This.inspection does not address how the.system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage oisposel system•Page 1 6117 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 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: The dwelling located at 112 Mistic Drive Marstons Mills is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 precast leach pits. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M ,•''V 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. Cityrrown State . Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. City/Town 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: 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 El 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 l5ins-3/13 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 M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. City/Town State Zip Code Date of Inspection 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd l5ins-3113 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 M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: '/2 2014— 14,000G, 2013— 140,000G, &2012— 124,000G Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 'RailW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is MArstons Mills Ma 02648 8/20/2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" 3" Scum thickness 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 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills" Ma 02648 8/20/2014 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date 1 Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0„ Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet inverts. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''F 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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 and stone was dry, no lush vegetation. No signs of past hydraulic overloading Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 page. City/Town 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.): 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.): t5ins•3113 - 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 112 Mistic Drive_ Property Address David Chernov Owner _..___._..__......-- _ Owner's Name information is MArstons Mills Ma 02648. 8/20/2014 required for every . _ _._ 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: Z hand-sketch in the area below ❑ drawing attached separately AI IYG A`Z 3'3 0-3 RZ � y .A,3 37 G3 3i- -Y (( 13-y 30 t5ins•3113 Tttle 5 Official Inspection Foim: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 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 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: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins•3/13 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 °M 112 Mistic Drive Property Address David Chernov Owner Owner's Name information is required for every MArstons Mills Ma 02648 8/20/2014 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f DATE:5/15/02 PROPERTY ADDRESS: 112-Mistic Drive --- ------------------- /y,�� � --Marstons-Mills ,Mass_ 02648 l ------------------------ RCEIVED On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1500 gallon septic tank. JUN 0 4 2002 2 . 1-Distribution box . TOWN OFBARNSTABLE 3. 2-600 gallon leaching pits . 6 'X4' xl2 ' HEALTH DEPT. Based on my inspection, I certify the following conditions: O 4 . This is a title five septic system. ( 78 Code ) 1 5 . The septic system is improper working :order O� 6 . at the present-,time . MAP Both of the leaching pits are presently dry . pp 7 . Pumped the septic tank at time of inspection . Heavy scup'nMA solids layers were present . LOT ; SIGNATURE:1- Name :_�_�_ Macomber �Jr.-_____ Company: Joseph_P_ Macomber-& Son , Inc , Address: Box 66 -------------------- _-Centerville , Ma ._02632-0066 Phone:---508_775_3338__ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks•Cesspools•Leachf lelds ,Ps.+t�nt+s+ � ,It1i'd111ft1� Town Sewer Connections P.O. Box 66 Centerville, MA 02632.0066 775.3338 775.6412 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I up, DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 112 Mistic Drive arstons Mills ,Mass . Owner's Name: Lynne Skillin Owner's Address: 5 15 02 Same Date of Inspection: 5/15/0 2 Name of Inspector: (please print) Joseph P.Macomber Jr . Company Name: J.P.Macomber & Son Inc . Mailing Address:Box 66 Centerv; llP ,Mass/ , 02632 Telephone Number: qnR-775—'i4i$ CERTIFICATION STATEMENT I certify that 1 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: Y Passes,. Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: �l✓��0� The system inspector shall bmit 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. 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 e n the future ut►der.the'same-or.different` conditions of.use: Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 112 Mistic Drive Marstons Mills Mass . Owner:Lynne Skiiiin Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. �ystemPasses. ivv 1 have not found any information hich indicates that any of the failure criteria described in 310 CMR 15.303 or to 3T MR 15.3 —exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is improper working order at t:he present time . Both . of: the 600 pits areT, .r.y:: _ 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"riot 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: V0 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: 4 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: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 112 Mistic Drive Marstons Mills ,Mass . Owner: Lynne Skillin Date of Inspection: 5 15/0 2 C. Further Evaluation is Required by the Board of Health: __J& 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: AM Cesspool or privy is within 50 feet of a surface water Alb 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. ejg The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 4P The system has a septic tank and SAS and the SAS is less than 100 feet b t 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: /U�/hE . 3 Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ProperryAddress: 112 Mistic Drive arstons Mil s , Mass . Owner: Lynne Skillin Date of Inspection:5/15/02 D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no" to each of the following for all inspections: Yes !�o /�ackup of sewage into facilin• 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 distribuuori box above outlet,invert due.to an overloaded or clogged SAS or l cesspool /I'�` :, �!x�il�x DAY _ f/ Liquid depth in,sssspaerl is Icss Than 6"below invert or available volume is less than h 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. i An portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface eAny ater supply. yportion of a cesspool or privy is within a Zone I of a public well. yportion 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 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 form.) 40 (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 e" 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 now 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) des no !�the system is within 400 feet of a surface drinking water supply 1the 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— 1WPA)or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered �es" in Section D above the large system has failed. The owner or operator of any large system considered a 5!enlficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR !5 304 The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 112 Mistic Drive Marstons Mills ,Mass . Owner:Lynne Skillin Date of Inspection: 5/15/0 2 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No/ 1l 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,lexxoludingthe 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: Yes no Existing information. For example, a plan at the Board of Health. t- /— 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)) 5 F) Q F- H UD �aCCLQ Pi v �J Ql m N of _ 3� L„ 0 Lod 7 co u, — —_ _ _— --------- —. cr w T_ O 0 L) s-� a-� Ul a--1 cy 2 m . - .. LOCATION �jC SEWAGE PERMIT 010, m VILLAGE CD QRfS��S �11Al5 CD }I � 1� `lp"nut E i A �Pif +��3L1U CKFfiOE SERICICE In 350 VITa��I►�t'Street Wvst Eara*fik.Mass.02668 s ' BUILDER 01t OWNT DATE PERMIT ISSUEO c�lJO1 � DAY E COMPLIANCE ISSUED '/� Q w .. . I of z o � II � I t. 0i m ED rU if, I U Page 6 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 112 Mistic Drive Marstons Mills , Mass . Owner: Lynne Ski ' i i.n Date of Inspection: 5/ 15/0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): ''l� Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):4 Is laundry on a separate sewage system ( es or no): AID [if yes separate inspection required] Laundry system inspected{yes or no): Seasonal use: (yes or no): _J6 2000—37 2 000 Water meter readings, if available(last 2 years usage(gpd)): g a 11 o n s=1019 . 18 G P D Sump pump(yes or no): //,0 ZUU1-109 , UU0 gal lons=463. 02 GPD Last date of occupancy: COMM ERCIAL11NDUSTRIA L Type of establishment: Design flow(based on 310 CMR 15.203): _ AW gpd Basis of design flow(seats.!persons/sgft,etc.): 41X 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: _ e� OTHER(describe): GENERAL INFORMATION Pumping Records _ Source of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped: O gallons-- How was quantity pumped determined? Reason for pumping:Pump ed 1500 gallon tank. Heavy scum & solids layers were present . TYPPOF 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 'Might from system owner) _Tight tank /a Attach a copy of the DEP approval Other(describe): Ajp.roximate aee of all components,date in tailed(if known) and spprce of information: Were sewage odors detected when arriving at the site(yes or no):f!!D 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 112 Mistic Drive Marstons Mills-,Mass . Owner: Lynne Lynnne Skillin Date of Inspection: 5/15/0 2 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:4/Dcast iron Z40 PVCN4 other(explain): &A Distance from private water supply well or suction line: Id',* Comments (on condition of joints, venting, evidence of leakage,etc.): Joints .appear tight . No evidence of leakage . The system is vented through- the house vents . ��y SEPTIC TANK: (locate on site plan)i6_mpflj � Depth below grade: Material of construction: t/concrete I&metal Wo fiberglass.tJd polyethylene Ndother(explain) i1,T If tanl: is metal list age:y0/ is age confirmed by a Certificate of Compliance(yes or no):.gL(attach a copy of certificate) Dimensions: >4'6"�oi. "u/' '" Sludge depth: 10 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: n Distance from top of scum to top of outlet tee or baffle: C3 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Pumped at time of inspection . Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels ,as related to:outlet invert;;evidence of leakage .etc,),.,., . . .. 1Pum the se ti v e—tank—is'�structurall " sound and shows no 2v!deRcR"0Fieakage . GREASE TRAP4J1q(locate on site plan) Depth below grade:-49 Material of construction: concrete metal llfiberglass/d/�4polyethylene mother (explain): Dimensions: Allf 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: _ 44 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Grease trap is not present , 7 Page 8 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:112 Mistic Drive Marstons Mi11s .Mass . Owner: Lynne Ski 1 1 i n Date of Inspection: 5/1 S/02 TIGHT or HOLDING TANK;�{i Vtaak must be pumped at time of inspection)(locate on site plan) Depth below grade: �/4 Material of construction: Ay-concretej4metal fiberglass ofd(lpolyethylene4,�Lother(explain): Dimensions: dH Capacity: Ali allons Design Flow: A4 gallons/day Alarm present (yes or no): _.,&g Alarm level: AP? Alarm in working order(yes or no): Pal Date of last pumping: A�$ Comments (condition of alarm and float switches, etc,): Tight or holding tanks are not present . DISTRIBUTION BOX: 2(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box has two lat rals No evidence of solids carry nvPr_ Nn avidanra of leakage into or nttt of the box PUMP CHAM BER4,44/f-(locate on site plan) Pumps in working order(yes or no):'414 Alarms in working order(yes or no): 2—p� Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): PilMp rhamher i c note reaLznt 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 112 Mistic Drive Marstons Mil s ,Mass . Owner:Lynne Skillin Date of Inspection: 5/15/0 2 SOIL ABSORPTION SYSTEM (SAS): y (locate on site plan,excavation not required) 2-600 gallon precast leaching pits . 6 'X 4 ' X12 ' Both are dry . If SAS not located explain why: Located ; See page Type leaching pits. number: q/ 0 leaching chambers, number: (0 A)n leaching galleries, number:0 A, leaching trenches, number, length: D VQ leaching fields, number, dimensions: A overflow cesspool, number: _0 i{J innovative/alternative system Type/name of technology: 212h )�yG 71 G� Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy sand to medium fine sand No signs of hydraulic failure or prinding . 1,r)jj,-,_Z_re dry Pits are dry . Vegetation is normal . CESSPOOLS4 !8. (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Q Depth —top of liquid to inlet invert: A114 Depth of solids layer: All) Depth of scum layer: Dimensions of cesspool: Materials of construction: ,sJ� Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspools are not present . PRIVYAJWe,(locate on site plan) Materials of construction: Dimensions: Depth of solids: d4d Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present 9 Pagc 10 0(1 I OFFICLkL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con►inucd) Proptrry Addref1: 112 Mistic Drive Mars tons 1 s , ass . Owocr: L nne i in Dltc of intpcctioo; 2 SKETCH OF SEWACE DISPOSAL SYSTEM Pioridc I skctch o(thc tcwl`t ditpotll Iy)tcm including tic; to et Icast two ptrmancnt rercrcncc landmarks o ocncNnukf. Locm 411 w(ll) within 100 (cct. Locatc where public water Iupply enters the building. BIZ ftlgShC Dr. , ritiafS�.nS VAAS 1 N 10 Page I 1 of.1I , OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 112 Mistic Drive Marstons Mills , Mass . Owner: Lynne ci in Date of Inspection: 5/ 15/07 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 00 feet Please indicate (check)all methods used to determine the high ground water elevation: �iSObtained from system design plans on record -,If checked, date of design plan reviewed: Observed site (abuttin roe bservation hole within 150 fee of SAS) � Q� Checked with local Board of Health-explain:Qi9jll/P'B4 Checked with local excavators, installers- ( ach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used ; Garety & Miller Model , 12/16/94 Water table above sea level . Used ; USGS Observation well data.June 1992 Used ; USGS Technical bulletin . 92-000-1 Plate #2 Janivary 1992 Annual ranges of ground water levels . I up Of Ground Leaching Pit �+�1- ,eet 1 Groundwater. �Feet Below Bottom of Pit High Groundwater Adjustmen t 1.8 ft per Fnmpter Method Therefore, the vertical separation distance between the bottom of the'leaching pit and the adjusted groundwater table is / / feet. 1l •rrn rr.-n rrr--rr arnr nr.•nmrs-nr..re*rrr.m:-.T+-r'aarr:re-mrrn m-nw rm�rren wt+ .. _ �• TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SFWACF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••—•••^T••.-•.:♦—T.11�^.T.TT�l1•n�T11"Slt•1TTlTTI"1'T.'1a"IIl1�Zf'IT1Q/—^ITr.TaCpST RTSIIRTiT�'RP'1• ATIIT►1'R1TfTP1 -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRES$ 112 Mistic Drive Marstons Mills ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # 079/041 OWNER' s NAME Lynne Skillin PART D - CERTIFICATION f NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber & Son Inc-,- COMPANY ADDRESS Box 66 Centerville , Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1578 R • CERTIFICATION STATEMENT R I certify that I have personally inspected the sewage disposaj system nt this address and that tlhe information reported is true , accurate , and omplete as of the time of -inspection , The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : /,/System: PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 , Any failure criteria not evaluated are �-s ...stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection whichh I have con ilcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , �tg. Inspector Signature ® Date —. -- nd copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or"'operator shall u pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CHR 16 - 305 . partd .doc LOCATION �I� ��� SEWAGE . PERMIT NO. L + -7 `VILLAGE rNS TjT44 "5 Ei A )6r*t.tjLTa 8ACKHOE SERVICE lnut 150 WalHut Street ( ,w6st •Barnstable, Mass. 02668 iN��t � "e" 026res- BUILDER . ' OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � / �� ... � . �caCci�� � '� ., v `� i i. � i � J �� 1 � - � � ��,� 7 N�;a��c ��,uC. c4ft ,_ g6-�g4- Fxs®� No........ _.. _.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for M-4paa i al Warhi Tomtrnrtuan ramit Application is hereby made for a Permit to Construct 011 or Repair ( ) an Individual Sewage Disposal System at .a?_ H c�+,- .... -- ----- -o!�--�........................................... Location-Address or Lot No. .--, .._ �_ �IJ�...••••....�... ........................ ....aa! ....a Q---•-....-- ...- .L.L._...�t���.:................... ---.. .----- Q .. ) Wa -••••------ �l1- 1l ?...-•Ak-t.....J! . ............................... ..w..... --- .......................... Installer Address Type of Building Size Lot. r %®d._.:Sq. feet `� Dwelling—No. of Bedrooms._...._...............................Expansion Attic ( ) Garbage Grinder (00'5 Other—Type of Building No. of ersons____________________________ Showers — Cafeteria yP g ---•--•--•--••---•......•-- P ( ) ( ) a Other fixtures .............................. .. <� Design Flow........: ••• ..............gallons per person per day. Total daily flow-___-4kD.:_.___....____..............gallons. Septic Tank—Liquid capacityl-500.gallons Length................ Width---------------- Diameter................ Depth................ xDisposal Trench—No. .................... Width.................... Total Length.._...._.....�.�__ Total leaching area....................sq. ft. 3 Seepage Pit No........�r------ Diameter......1�-_.____ Depth below inlet_......3 .`.)... Total leaching area.._44.6...sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by. 4b&f..ZA;6.-.4....................................... Dateln_.. ................ ;.a Test Pit No. l_____L......minutes per inch Depth of Test Pit------tom....... Depth to ground water------LP_-__--_ --. w Test Pit No. 2.._.Z.....minutes per inch Depth of Test Pit------ Depth to ground water........................ ---------------------------------------•----------------------------------------.._......._......•--......................................................... 0 Description of Soil.......KOb........ .* -----------•--------------------------------------------------------------------------------- -------------------- V ----------------------------------------------- --------------------------- ------------------------------ --------------------------- ---------------------------------- .....------ -------- ------------.... W -•--••••--- ------------•-••-----••--------•--•------••-....--••--••---•---------------••••---•---•----•--•--••--------•...--------•-----••-••••--•-••-•--•--•--------•-•-----••-......--••-•-•-••••--- VNature 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 iIT �s p of the State Sanitary Code— The undersigned further agrees not to place the system in oper tion until a Certificate o mplia ce n issued by the boar f h _ 9D egith ned .............................. a .............. ate App ication Approved By.......................S. . --••.....AZ .......... ..-- Date Application Disapproved for the following reasons-----------------------------------------------•-----------------------------------------•-•---------•••••-•-.._ --------------------------------------------------•-----------•--•--------...................--------------------------------------------------------------.........-----------------•-••---•---••-•---- Date PermitNo......................................................... Issued....................................................... Date n ' � No......................... FEs............._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .........oF....,��/ J.: ------------------------------------- Applirtatiun for Disposal Works Tonstrurtiun rrmi# Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: .... Location-Address ................................................................................ or Lot No. .............. --.. ..QX..� 'fo ���y�f��j.,..1111.?l? .::.. ................ Owe . .....................� W ..............� ----....t... -- .................•---...........-- --..fit (� = 1 °..... � ..................... a Installer Address Type of Building Size Lot—��f 7— ®--.....Sq. feet U Dwelling—No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Grinder (,-I '4 Other—Type of Building No. of persons............................ Showers — Cafeteria 0.1 YP g P ( ) ( ) P4 Other fixtures ----------------------------•--• . W Design Flow.........IAD............................gallons per person per day. Total daily flow..........( .............._------gallons. WSeptic Tank—Liquid'capacity.\ •gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ()v.) Dosing tank ( ) Percolation Test Results Performed by.g ��_-- ':.................................... Date.7/2K"*.................. aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •------------- -----------------------------------------------------------------••------•-----•-...........••••----•-------------._.....-•--...----••.-- ODescription of Soil......M ,.....,. p.............................................................................................................................. V ----------- -----------•---------------•-----------• ------------------------ -------------------- --_------------------------------ •------------ .------------ ----------- ..._...------ ---------------- W •---••----•------•----------------••••-•-•---••••-••••-••----•••---•••--•-•••--••••......--•--••.••-----•--••-------•------••---•••-•-••••••--••••••••-••-•------•••••••••-•-•---•-•---------------•--- VNature 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 I.Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in ope ation until a Certificate o mplia ce en issued by t oar heal ...'t....� q Sig�ed—'GC� .... ...:4/� ............ Ap lication Approved By.................. •• •-`---------------- .•-•-- ..................... ----•-•. �� ------------ Date Application Disapproved for the following reasons:................................................................................................................ ....................................................•-•--------------------......._.._......-•-•--•--•--............................................................................................... Date PermitNo....................................................--... Issue_d....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........OF....o6o*�.....11�.f ........ (9rdifirtttr of Tout lianrr THIS IS TO CERTIFY, That the Individual wage Disposal System constructed (S( ) or Repaired ( ) by-------------------------------------------••-•.-----•--.1.�-----�-------- i e ®----N! .... l'1.E1.. . .......................................................... nstaller ` d� at...................................................................................... .C............ ........0----MA.......................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as desgribed in the application for Disposal Works Construction Permit No._-__�.... . ._.___.._.. dated._...-_-_.-.IS' .°'�- _19---4....:........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE SYSTEM WILL F NC IO SATISFACTORY. DATE..............1.j?.. .................................................. Inspector..............----.......--- .................................................... i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 9 yH�EALLTH . � ........OF........ �e04 .4........................... No. q FEE.__�....� ............... ............... Disposal •- Disposal Works contra ' n rrmit Permission is hereby granted.................................. hV... k��-4 .. to Construct ( or Repair ( _) an Individual Sewage Disposal System at No......................-- ft `�........ M1 tt'.Lk..----.--••--oi i!t Street as shown on the application for Disposal Works Construction Permit No...................'�.$Dated.._-____ '�._.._.....�............ - �� ....................... Boar, f Health DATE................. -...-----•--•---..�....------•- r FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r �: � ..•-� p�si��✓ opt�~Q • �= � � �5�1�r � � a 1� 2. 51►:1GI. ram!ic:.�� -4 739wvohn _. - It.� ) sd�clly 4so aoa6m> 1,��'i-I c. 'ra N►�.._ ado +-Zap 7 ' �o l Pb .. V 5 I Soo GAL firJ L. . ( OT "T. 'D izlVE- 1t;'! 'Po,5,4L. . ' 7 �IT"S- y5c3 Z- L©a ��L 14 j���C:�t G��'7 � �il'DGulALL ,QII• lSd �c2- 3o8 SF :200 11D C►9'D OF `T07A LLL -D L•�bd a ( D'"1 � � ���Y �"�°�'� � P'TER G RICHARD SULLIVAN -rd TA L `�1 I L•/ Fw.= 41,eo D dg-M O K- A. No. 23733 BAXTER CA� Al., No. ..�. TWIT T31 �TLIDGb UZ. 1�Glgs A* 1-0o FFs� sTE,A t , L. STV {OQ OVAL EN�� i TESr'Ho�E 7 7 8 s C 4,- T2I Sees To .1, OF 4+tUb S. a-l7•�-6. XtE, SG `� TaafHd #3 (�G= 58,E FG• = �� ��,, r- �_. � - _._- - ._..__..._. : t-i--So J;;` BOX S3 L G.4L. 53•� GAG 7—AN/G $` M�� SQub :• ��>rs %s 53.2 53•4 eE.2T/F/Ey PGOT pl-AA/ w14 f ,b F . ¢ ✓�GGLA7 i/ ,o QQTE ¢-2 ,6U I 1y.4/ WA rlPZ Coe¢ �v Q_44•,' /d /Z WLT SANn No cva naz P'zaPax ZAO-' Z0 3 _ 3 . �- / GEeT/may T�,aT TyE Faal.)Z;1,4 7701J�jNDVt�it/ . bVe. ANC f�'J-J//JGY_ ,2�Qv/,2Ek1�NrS oA� Ti 14 leEaiXr.,er491-40vo svevEya,�S _- GcVt /7 ' 4_z5' T//!t�G.•�it/ /.s Ala7- ,4H%11-57.2 To EST.�I�G/Sy ;'N r i Li 4/2S./�!o 70 Wit,= dp,d- 1'7--0 ,.ate zl+ 4V alec•- el 544-S � ex 44 c-xn nn sB 54- OF iyq ti,� I i SULQVAN • No:29733 ' is r ��R la�a}1l S MCHARD A. �a BAXTER • No.21C48 ' - , Permit Number: Date: Completed by HIGH. GROUND-WATER LEVEL COMPUTATION Site Location: /.S7 14 to Lot No. Owner: b'> 13ourla r Address: Contractor: z5-!/&-TLTT 4oNST Address: Notes: i i STEP 1 Measure depth to water table to nearest 1/10 ft. . . . . .. .... . . . .. . . . . . . . ... . . . . . . _ /7/F& E:o date i STEP 2 Us.ing Water-Level Range Zone and Index Well Map locate site and' determinei A) -Appropriate index well B) Water-level range zone . . . . . . . . . . . . T� STEP 3 Using monthly report"Current Water Resources Conditlons" determine current depth to. water level for index well .. . . ... / mo yr STEP 4 Using Table of. Water-level Adjustments for index well STEP 2A ., current depth to water level for ind.ex .well j (STEP 3) , and water-level zone (STEP 2B) -determine. 4, 5 water-level adjustment . . . . . . . . . . . . . . . . . . . . . . STEP STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) 00 from measured depth to water Eil level at site (STEP 1)