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HomeMy WebLinkAbout0151 OLDE HOMESTEAD DRIVE - Health 151 Olde Homestead Drive Marstons Mills P A = 043 001015 I i Commonwealth of Massachusetts b-113-LOO/r'd/,� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 151 Olde Homestead Drive Property Address Cif Mary Fitzsimmons Owner Owner's Name 07 information is s requirec for every Marstons Mills MA 02648 3-10-16 page. City/Town State Zip Code Date of Insp%on do Cn Inspection results must be submitted on this form. Inspection forms may not be-altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �/��1 ``���q�Urrrnu���/Z on the computer, 77 ``����`�(N�F use onlythe tab ��` �:• key to move your 1. Inspector: �o� : ,oyG curor-do not James D.Sears ? JAMES •:m= use the return Name of Inspector :y key.. o Capewide Enterprises, LLC *' ' Company Name `` 153 Commercial Street ��, 5 INSPE ��\` Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S 1623 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 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C 3-10-16 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �o his ' t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposa S tem•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M s 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 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: ® 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: The system is a 1000 Gal. Tank D Box and pit. 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. City/Town 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 systems 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 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M ,•'' 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. Cityrrown 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 supp'iy 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 y to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than '/z day flow P,,T t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 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 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. 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 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping Information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: The sytem is a 1000 Gal. Tank D Box and pit. Number of current residents: 1 I Does residence have a garbage grinder? ❑ Yes ® No. Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2014-55,000Gals g ( y g (gPd))" 2015-49,000Gals Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required)for every Marstons Mills MA 02648 3-10-16 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: NA 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Permit#86 -778/3 -2016 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26" 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.): Pipeing is 4" PVC SCH 40. Septic Tank (locate on site plan): Depth below grade: 16" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H- 10 Sludge depth: 1" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. CitylTown 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 29" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 16" below grade w/inlet cover at 7". Inlet Tee Outlet Baffle. No sign of leak age or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;u 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 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 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 4 v Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 16"-2' below grade w/one line out. Box is new-3-2016 w/cover at 8". PumpChamber locate on site plan): ( P ) Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I * 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 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit. Pit at 28" below grade w/cover at 16". Pit has 2'water. No sign of over loading or solid carry over. No high stain line. 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 wM. 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name rero iced for is Marstons Mills MA 02648 3-10-16 required for every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name requir d for is Marstons Mills MA 02648 3-10-16 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � !r 13-i- f� 0 f B 35"A t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exaim: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells JVa Estimated depth to igh round 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: Abutting property and lot high. No G.W.12'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r— Commonwealth of Massachusetts w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 151 Olde Homestead Drive Property Address Mary Fitzsimmons Owner Owner's Name information is required for every Marstons Mills MA 02648 3-10-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECT r A MAY 0 6 2003 TOWN OF BARNSTABLE TITLE 5 TH,r?EPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 0 O k Owner's Name: MURPHY C(O CENTURY 21 Owner's Address: 877 MAIN ST OSTERVILLE MA.02655 Date of Inspection: 4/9/03 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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: X Passes _ Conditional asses _ Needs Fu Evaluation by the Local Approving Authority Fails Inspector's Signature: t!� Date: 4/9/03 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec on. 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 THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Titla 5 TncnPrtinn Fnrm 6/15/1000 1 Page 2�of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 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 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 n/a "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: n/a Page 4,of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 I Date of Inspection: 4/9/03 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 NOT IN THE,LAST YEAR INFO FROM AGENT. 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 form.] 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. 4 Page 5-of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 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)] Page 6'of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 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):NO Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): NO 1 Last date of occupancy:3/25/03 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR INFO FROM AGENT Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Ovarflow cesspool _Pri-q _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innz)vative/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): n/a Approximate age of all components,date installed(if known)and source of information: 1986-778 Were sewage odors detected when arriving at the site(yes or no): NO F Page Tof 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 BUILDING SEWER(locate on site plan) Depth below grade: 16" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions: L 8' 6"H 5' 7" W 4' 10`1 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness:2" 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: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8'of 11 OFFIC IAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND AND SYSTEM SHOWS NO SIGNS OF FAILURE. PUMP CHAMBER:-(locate on site plan) Pumas in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a � R Page 9'of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION AND THE STAIN LINES INDICATE THE PIT HAS NOT HAD MORE THAN 2' IN IT.THE BOTTOM IS AT 8' 6"- CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 9 f 1 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 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. `• w `Rc�! 6a[L �A aC) Aq ISN A& a3N Al)L M IL bcc�5", 3Sti in 'Page I 1 of I I " OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continu:A) Property Address: 151 OLDE HOMESTEAD DR MARSTONS MILLS 02648 Owner: MURPHY C/O CENTURY 21 Date of Inspection: 4/9/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED FROM HAND AUGER AND USGS DATA-NO WATER AT 12' 11 No. v b V> t) F � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS NpliLation for Misposal *pBtem Construction Permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.15( 0 r-DE Owner's Name,Address,and Tel.No. Assessor's Map/Parcel O M M MAK-1 r OOl ®f _ 151 OL-D t Installer's Name,Address,and lel.No. 5oy-&J'71-8871 Designer's Name,Address,and Tel.No. < �4AtO Wtbc s D S C f C.. nn 15 CO E e_t 5`e G�1t4St�mt N rT Type of Building: Dwelling No.of Bedrooms Lot Size 1�t ,,3 Lj 4t! sq.ft. Garbage Grinder( ) Other Type of Building ( Tt($( No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) RG I�ok Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boaurd of Health. Si Date 3 "oZ��sO Application Approved by 2kDate?T,zQa Application Disapproved by Date for the following reasons Permit No. Date Issued }` No. L yl b — V J &I FeP� THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for jBisposaY 6pstem Construction 3pPrmit - Application for a Permit to Construct( ) Repair(� Upgrade( ),Abandon( ) [:]Complete System AIndividual Components Location Address or Lot No.15( OLDE 14004FSXX*tl ()R Owner's Name,Address,and Tel.No. Assessor's Map/Parcel O M M MARN I F 1-( l 5YONS 00l01 151 O -DG op PW97 Installer's Name,Address,and lel.No. S g-q-77-8 8-71 Designer's Name,Address,and Tel.No. (2Ai0&wtbC GKP'E309A-(S&5 LL<- 5 Co!y_ d 5-r N 4 Type of Building: Dwelling No.of Bedrooms Lot Size a ,3 '- sq.ft. Garbage Grinder( ) Other Type of Building ( No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) RpL eg- ok Date last inspected: Agreement: _. 3~ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar`of Health. Si �! Date 3 -�•a0l{o Application Approved b I PF' PP Y ��,. �� Date y Application Disapproved by Date for the following reasons Permit No. L Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of (20ItttlYlatttP THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(K Upgraded( ) Abandoned( )by OW t-: tJ(T)r L4f at 151 OC-DG 14OK•f 657e--4b 1)k M Ji/�_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 USJd Q �i ' ated y �I"t Installer 1�6wio6 t��7 Q�4� L-4-f, Designer &j,/o #bedrooms ((L Approved design flow, h) 4 gpd The issuance If th', permit shall not be construed as a guarantee that the system wi fun do as designed. Date q I Inspector f �, J No. U I Fee _. THE COMMONWEALTH OF MASSACHUSETTS �T PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal *pBtem Construction permit Permission is hereby granted to Construct( ) Repair X) Upgrade( ) Abando^n'( ) System located at 7 r r�(.�}t i�(��( "jf�ij� �1(J� P/AP-SMNS 141 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5,and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date 3/y/�h_ Approved by 61 �� AsBuilt Page 1 of 1 TOWN OF BARN��S,��TABLE � p LOCATION !1' �P• L14 t S-(0 f )tSEWAGE# O / f VILLAGE ASSESSOR'S MAP& LOT_,(_ r'IISTALLER'S NAME & PHONE NOA-J IV-n"1t'I_l At .SEPTIC TANK CAPACITY LEACHING FACILITY:(type)Le (size) „ NO.OF BEDROOMS^PRIVATE WELL OR•.UBLIC WATER- a BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED- 7 l - 6-- VARIANCE GRANTED: Yes No t tikill1 + i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=043001015&seq=1 3/4/2016 TOWN OF BARNSTABLE V LOCATIONIi. I�-tift�A y l`>I, . ' tf�pNCl �r'��C-� ) SEWAGE # O `" VILLAGE I( � �� 9 E(-+w ASSESSOR'S MAP & LOT _ I-INSTALLER'S NAME PHONE NO 11� 19-tr--o l 1` 1 f4 f) '-SEPTIC TANK CAPACITY LEACHING FACILITY:(type)[4?04 N R (size) NO. OF BEDROOMS PRIVATE WELL OR4PUUBL C_WAT�BRr BUILDER OR OWNER OW_ DATE PERMIT ISSUED: I DATE .COMPLIANCE ISSUED: ,77 - I - $7 VARIANCE GRANTED: Yes No LOT s rZ I I' ASSESSORS MAP NO: PARCEL NO.: FRx.1....721,0.0_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............rjau'o'Le..........OF......&UtW12.4.& . ................................................. Appliration for Dhipatial Workii Toutitrurtion Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 41 'ee..... ----I.'' ................................................. ../1 ,0 Location-Address , No. ...DA.......YO.TYLV40)................................................. ...HAAnthd1W......H&M............................................... Owner Address -------------------".......... ......... nstaller Address < Type of Building Size Lot.e_W....8,58......Sq. feet U Dwelling—No. of Bedrooms.______.. ................Expansion Attic Garbage Grinder '_l PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria PL, Other fixtures ------------------------------------------------------------------------------------------------------------------------------------------------------ Design Flow.........6.5..........................gallons per person per day. Total daily flow--------3W.........................gallons. P4 Septic Tank—Liquid'capacity.IDOD..gallons Length....2....... Width.......4a..... Diameter________________ Depth__._________.... Disposal Trench—No_.................... Width.................... Total Length.................... Total leaching area---------------------sq. f t. Seepage Pit No.......I------------ Diameter....9...... ...... Depth below inlet......6........... Total leaching area....af.0.10..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-----JJ Zn...... ............... Date.......Vllelki6.............. `4 Test Pit No. I.......2--minutes per inch Depth of Test Pit____________________ Depth to ground water_____._.___.___.__...__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.___._._____-___.__. Depth to ground water_._._______._______._--. ....................................................I................................................................................................ 0 Description of Soil__.._.12—.P?...............Tz�2p-----q---sLJt�vzft-------------------------------------------------------------------------------------------------- �41 '1 ...................................A--)-a.,. U ......... ... .. ................................................................................................ .............................................................NO----4CA.1a ........................................................................... ----------------------------U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------*------ ............................I................... ............................................... Agreement: T 'D C"V The undersigned agrees to install the aforedescribed ivid. ual ewage Disposal System in accordance th the provisions of'T'!.Zj 5 of the State Sanitary C sy I de T eOder ned turther agrees not to place e syst in operation until a Certificate of Compliance has bee ' is of health. Signed- .. . ............ .. .. ............................. ............ at Application Approved BY ... ... .. . ..... ........................ ............ ............. Date Application Disapproved for the following reasons:.............................................................................................................. .......................................................................................................................................................................................................... Date Permit No —.N1 V7­5R�.... Issued....................................................... Daft /Jcv1t �y.3-/ lJ Ftzs ....7,5r.4.0--_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -----......To!5 . OF....13.sir.olAA................................................. ' Appliration for Disposal Works Tnnstrndinn rumit Application is hereby made for a Permit to Construct (SIG) or Repair ( ) an Individual Sewage Disposal System at: . ... ��._...��. 2.....J#n7w. - ad--- lla t ......... ... .....to Location-Address Lot No. . ..}16Ttot'.�C1 ......................... `�1 2L) 1.�t'LL� a ............................................... Owner Address a ._d1sRJ.:-I- -----•- -�-=:="`e�.. ---------------------- •-------- •......... -••'..-eL=S,�! `. &S_1.>. .Y_ ...................... Installer Address Q Type of Building Size Lot. J_.'-58--------Sq. feet U Dwelling—No. of Bedrooms........3...B.JR....................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P 1 Other fixtures -------------------------------• •• . W Design Flow.........55............................gallons per person per day. Total daily flow_.....-.,t_30...........................gallons. WSeptic Tank—Liquid capacity LD0...gallons Length...c ....... Width.....1n------- Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.....1-------------- Diameter-_S.......__.___. Depth below inlet....?............ Total leaching area.........Q.G....sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---- ........ t.!d s =S__ <. ................. Date.... ................ ,.1 Test Pit No. I......_4......minutes per inch Depth of Test Pit.................... Depth to ground water-----------------_-____. ti, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...__._____-___-________ a •--•••I•••-••---------•-•--•-••-••......•.••-• •---•••----•-•..............•-•---------------------•--••--------•.........-••---......---•-•------......•. O Description of Soil...._d=:_ _............TC_p..... UW1UC� ..----------•--------•-------------------------------------------------------------------------------------•-•---- Nature of Repairs or Alterations—Answer when applicable................................................................................................ .............................................. -------------------•----------------..................---•••--- Agreement: The undersigned agrees to install the aforedescribe TI dividua' ewage Disposal System in accordance it the provisions of TT T 1 of the State Sanitary Cbde ii�e, rode -igned further agrees not to place he sys m in operation until a Certificate of Compliance has be is b d of health. r Signe ( ---.......-•-- _ --......--- -� y Date Application Approved B}c ."`��.,!.____-_^I _::1 .. ...A�Date _ ...... Application Disapproved for the following reasons:____________________________________________________________________________ ...•••-•--••••••••••••-•••_..._......••••--•••--•---•---•------••-••.................................••---•---•••--•--•--••••••••-•-•--•••-••••-•-•-----•-•••-•-••••••-•••----••------••--••---••••-•-•- Date Permit No,_ -----._-.l_ ........ Issued...................... ............. Date THE COMMONWEALTH OF MASSACHUSETTS -� BOARD OF HEALTH .............l.G.' !lar............OF.....:.6A4.t'LDJ Ad. ......................................... vlorrtifirate laf Toutpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed') or Repaired ( } by------ ........H.i: ,. Installer at. ``o = lr f '??=1�12L'� �2�t� --------------- Q. /}•tG!CL4? / has been installed in accordance with the provisions of T i T IE j of The State Sanitary Code de4Eribed in the application for Disposal Works Construction Permit `o'....._.......�``�..-_... dated__..-�V.AANTEE _�_/_S;R_.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUA THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................•�.?• =---�._0.......................... Inspector....4 ..... ---------- J )) THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �Y .............. FEEZ ................ Disposal Works 041nstrudion ami# Permission is hereby granted .! t. �'`-- --------- ----- ----- to Construct S` or Repair ( )_ an Individual Sewage Disposal System r T ..-_ ..... Street as shown on the application for Disposal Works Construction Permit N �__�.. Dated..�..�!L.-'� .:. ,. .�� i/� + C Board of Health ✓ATE :C° �h-�-•.-�a.f...�...�-��C1......... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS '� �•!! -..� Imo' ;_. •� �y� a,,.y 5 i • JY ._._ i _{._.....-,.�.�.._. _. . _ _ S►•1 SET �O r 2. 'j:►rc[ i:.E. .Tf4M11 '3" Dvbol:vk 1 �L_i 1 f s e i �P�Z1k Uf M•gss. PETER SULLIVAN 1�I6—oo (-r `^- SL- 1 C)06 �ALJ-0 Lx �:,� i���IJ,k:. No. 2,9733 -1 r g �o I ?ELG1'T� ';. 15C>tr o.2.5 6/6 F • 376 :�.tFTD, GA t�ALI"C`� r ' So 5 r�.1.�G�/5 F• 5 0 �->:��� 1 , '. �E51�h.-1�t�.�!1�I.ATI`�3..J��f•��C"t�.. :�c� I•�', '�•��l 1�2 I U�.:1�. � `��,: - , +fiti4`4x' i-IT ��"1 . . . •• Y� :�NV 1taV - thl.•J i1J.`/ '��►1l.,. Icy r L o >~ lOpO ExA.I.P►-r v 1 w4sH6pl. I_..oati-r,o�-1 h�2s�►.95 f��t_�s s m o ` Tt:= u� 11 _ � � 1 C U . ZOP S E37 -MAX T'l-t 1;.: Gowl\ .ovjiIT}�"�?�F� _ I ` , '��L•Y t 5-C�:i'.LC%�f.�.t° �jc.t;>:?V=Y4�'S j ✓�:.1`a��. `�tQ_U1�.�ME�-1`S`� t?t-'T'h h. 7'c�W� CY C 1,aor Lo L u N. UoT' -0/h "6 bU},,,� Of Mgss • PETER -_. Nor97W v 1..`� 171 198ra I-,Lc- 4c) :_. l t"1 r r�CHAR- - BAXTER P!a 24Q4$ T - Low- �4\, t f a. tv /Q- Jt~ �.`( r 4. - - __ - C�ry iti`� tK�rvsl:V :$ All .%N:IC GUIDE LINE 105641 10 X 10 TO THE ING41