Loading...
HomeMy WebLinkAbout1541 RACE LANE - Health /� MW RACE LANE, MARST.MILLS A= o7 - 13 � i _I TOWN OF BARNSTABi.E ✓ ?�N I 9'1 IPe&te l�a nrt SEWAGE # l/ F,:—,"-AEEr �S Yee t ��S ASSESSOR'S MAP & LOT r7 % , SNAME&PHONE NO. MiCk 'e t ACe AW� ,5b8-Itsr-790a SEPTIC TANK CAPACITY LEACHING FACILITY: (type), Vjt (size) ig , NO.OF BEDROOMS n BUILDER OR OWNER CA., AL4, PERMITDATE:_ COMPLIANCE DATE: + 2 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom.of Leaching Facility-=-- -44 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) V Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by— r �___ _ .,.._r .,7w '` ,. .:� 1. ����. -�i� � � .i i� ,. ' .i ..{ � _ ` �.._ � •, ��' ,.� •.«eau="'.!. r y. i � .,}y., �� .. i �/� i ,\ ;7' ��Y �-r . � a i COMMONWEALTH OF MA MACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF EN moN3mNTAL ftcincnoN ONE WRMR STREET, BOSTON 1idA 02108 (617)292.5600 AR05Z PAUL CELLUCCI D,k.VI::)B.VKTFL9 $I-,SSMACE SEWAGE DISPOSAL SVSTM NSPECTIOM F�OF{M Coaumi&siaan PART A I�14 C0191111CATIM 1 �aV Addmsva;. 3�,/ ka c c if,,a Kt meow of Owner T h .X r Tr vt l L S Adtaaea a1 Ow-to /•S Y/ T ah c Dam of illsofOaWlt: (i 00 M 4 Ys*-ns m, a s, f'!ass, 0 a('`1e fifl.itte of'Oil a:er:(Pbo e 1 t 44 awl.oc► ayasani Yialiaatarpiirstiaret to Seto rt 15.340 of Irmo 6 mo CNN 16.00M 1%fti Ad*#M: It 16 a oat 6 K r 10"#y that I have personally Inspected des&*wage disposal system at this address and that the Information reported below is truc accurerte call oemftivta as of the time of►AepootlOn The inspection was performed based on my training and experience In the proper tim.likin and malrrtsnance of on-oft sewage diapos l 9-1-stems. The system: CarteltlonallY►as�iee N*ede Further Eviluatfon By the Local ApprovMg Authorky _ Fait& fa.�.a*.re siSltaia.e: ."L DOW- /�ov The System inspector&hall submit 8 copy of this Inapeotion report to the Approv"Authorky 48oard of Health or 06P)wfthin tarty I201 days of Oomphllydng tme Inspection. if IN system is a shared system or has a design flow of 10,000 gpd or greater,the inspector enei tM(I mgstem I)wnef shah suanit the to" to the"Wrolsdate regional ohke of the Department of Envhonmentel Protection. The original should be owl to dte system ownerOWe **glee sent to the buyirr,if*ppikeMe, end the approvMg audIlO ty. MOTU AND COMMENTS RECEIVED 2 9 2000 TOWN OF BARNSTABLE HEALTH DEPT. revised 9/2/98 f vIat11 .,arena an RecrdW POW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.•''y Ronald Pariseau Property Address 1541 Race Lane Owner Owners Name information is Marstons Mills Ma 02648 7/26/2011 required for every page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. C y e Enterprises � Company Name 153 Commercial St. Company Address Mashpee Ma. 02649 Cityfrown 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 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 16.340 of Title 5(31.0 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/26/2011 Inspectors 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 sfia shared:aystem or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform.in the future under the same or different conditions of use. I LMS,ins1/10 Title 5 Official Inspection Form:Subwftce L Disposal System•Page 1 of 17 �n � . i.. tfP'r..�x� f! �'-I I �x ,;.� •k"'•'S.r.�,�L iY. .. . x., .. f .'S °- mat! t,- .K M d mv, y k!, �S.";, :t tWay-ON javiraw f ,c l,:.°wF1 (r « a f':,• � i:'„ �' ..4 �S_. c. c' '`S ET..la3.?. x:C.<;di_I * P l ?s'. +.. t t:v47 ' i`f{c f r i �..'��.. Y* :.r,T'' .�', f•.. ,.. .. x�.'71r' .�.v ;:e •�, ti'.:r" xt�, , ,` . ., "• .. �r '!n.wi 3'•'p�.. ,i� e,�,--Y� ,E,-L± 11ta1'..•.�..YY= s�i a�"a,t,- L ..ti.. �:'i -i' 1 . i .... .. ' _ —Al . ( .` "Y' i�r, } i' p,r r Ft`4 ? •7 r t r11 "v 'r a'e ►r'r3x -i T? 'c'!o 7 x,,. ' t .. f O� .. J ""E'•�t' y :/;�? � E�. S[ .. .+P,.9_ :i Y,Y„* ¢{ SI, a J �•� '� 'v� .. [' - OA . q .�+^�f�11:t.k�,.�'i �,� "'f'" ...,,?!€.° 4:} x , r;*a'y'jy, l�liE'�.:1 ,1'Boi.J ,1 .Y �:ti' +'h•�i _::1 �'.:r' , ! •� :'i»�: �'1 � �"i�d.r c�a x`$:'.:r5#k.�S�ar� "�r s ,•l:u � �'ii;y .:,.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owners Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. City/Town 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 dwelling located at 1541 Race Lane Marstons Mills Ma. is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box, and 2 1000 gallon pre-cast leach pits. 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): '3 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. Cityfrown State Zip Code Date of Inspection B. Certification (cost.) 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•11/10 Title 5 official Inspection Forth: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 Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. CitylTown 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6°below invert or available volume is less than %day flow t5ins•11110 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 Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 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•11110 Tma 5 Official Inspection Form:Subsurface see Disposal system-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd t5ins•11/10 Title 5 Official Inspection Forth: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 Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is Marstons Mills Ma 02648 7/26/2011 required for every 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?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 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: t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Rigmp Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owners Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. C4rrown 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•11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is Marstons Mills Ma 02648 7/26/2011 required for every � page. Cityrrown 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 installed 1987 per town records 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: El cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through 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: 5" l5ins•11110 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 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 3.5' 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 10" How were dimensions determined? opened covers and 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 as maintenance. Outlet tee intact and in good condition. Water level was at bottom of outlet, tank was structurally sound and not leaking. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts uvTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. City/Town 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "r IRonald Pariseau Property Address '1541 Race Lane Owner Owner's Name information is Marstons Mills Ma 02648 7/26/2011 required for every �I page. Cityrrown State Zip Code Date of InspediDn D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert off 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.): water level in d box was even with both outlets, box was solid and not leaking. 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Lt5m.-11/110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owners Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2x1000 ❑ 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.): At time of inspection leach pit(#4 on as-built) had 4'of available leaching and 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. Cityfrown 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•11/1l7 Title 6 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 Ronald Pariseau Property Address 1541 Race Lane Owner Owners Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately DD I �,-f 3 7 A-2 ZS' IN 41 ' dti 0-8 gc A-3 3S' 8-3 yb' J eACK PITS A-q %r A G,y` t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 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: 50+ 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: Town of Barnstable groundwater contour map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ronald Pariseau Property Address 1541 Race Lane Owner Owner's Name information is required for every Marstons Mills Ma 02648 7/26/2011 page. Cityrrawn State Zip Code Date of Inspedion E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'v 1541 Race Lane of �>q Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name rdb P.O.Box 763 Company Address Centerville Ma. 02632 !� emm City/Town State Zip Code (508)428-4028 S14454 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 =+ r 2/20/2008 ( ' 2- Inspector's Signature Date X ^� The system inspector shall submit a copy of this inspection report to the Approving Authority(B©ard of Health orDEP)within 30 days of completing this inspection. If the system is a 'hared s}r�stemror has a design flow of 10,000 gpd or greater, the inspector and the system owner s all subhnft 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. 1141 Race Lane•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town 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 septic system is in proper working order at the present time. 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 dletermined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 1541 Race Lane•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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: 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. 1541 Race Lane•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance- **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 1541 Race Lane•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. An portion of a cesspool or privy is within 50 feet of a private water supply ❑ ® YP P p Y p PPY 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. 1541 Race Lane•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® 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)] 1541 Race Lane•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 I Commonwealth of Massachusetts W -Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:31,000 g ( y g (gpd))-. 2007:13,000 Sump pump? ❑ Yes ❑ No Last date of occupancy: 2/20/2008Date 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: Last date of occupancy/use: Date Other(describe): 1541 Race Lane•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ - Other(describe): Approximate age of all components, date installed (if known)and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No 1541 Race Lane•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: - e0+ t Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: feeetet 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 gallon 2" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8„ Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 1541 Race Lane-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts rz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town 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.): Pump tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be 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 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): 1541 Race Lane-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N.o 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.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakageinto or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 1541 Race Lane 12/C7 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: / Type. ® leaching pits number: 2-1000 gallon ❑ 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 sail, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failue.Leach Pits were dry at time of inspection.Pit# 1 stain line was 2' below invert.Pit#2 stain line was 3' below invert. 1541 Race Lane-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1541 Race Lane Property Address Brad Pariseau Owner Owrder's Name information is required for Marstons Mills Ma. 02648 2/20/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1541 Race Lane-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 r Map Page 1 of 2 Towri of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size 130 ❑ zoom Out J J ;JIn '' II , y- - 37" Y3 6� 0 20 Feet s : I Set Scale 1" = 20 I Aerial Photos r`r —;� hk onnr_onn7 Tn.., of RAA A11 rinhfe rocon, http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=047139&map... 2/20/2008 Commonwealth of Massachusetts W :Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1541 Race Lane Property Address Brad Pariseau Owner Owner's Name information is Marstons Mills Ma. 02648 2/20/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 60' 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:Gaherty& Miller model 12/16/94 ground water elevations.USED:USGS observation well data.USED:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 1541 Race Lane•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 I r Town of Barnstable �OF THE r yip ti� Regulatory Services EAM ,,,W,B Thomas F. Geiler,Director MOSS. 9�pTE1639. Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. i b- COMMONWEALTH OF MAl'MACHUSETTS EuCUTIVE OFFICE OF EM1RONMENTAL AFFAIRS DEPARThmNT OF ENv=NmmNTAL ftomCTIm ONE WIWMR STREET, BOSTON IAA 02108 (617) 292.6600 '3i—CORE secv,tary ARGTIO PAUL CELLUCCE A,tVI:?B.r"KUM (sawrttor Costmi>,siansr 21:I1SSURFACE SEWAGE 0I51100M SYs"IHs NsfPE.CT9®M FAIL PA"A �Sy ►T" Masers of Oennsr i. l e r TInez 111a►a y$�r.5 �10 ll3 I►defrsae a#fAierner�. P�.L .g&.. 4 aft e' ae elf limpou or: 2 It C* M 4 ry)6,,s Mills Mass, ®a G�� mwm at s a� f 1 an a DEP ovelow hillrsom.porasuep it to section is.sw of insis s mo cma t1f.D001 �MfAlle7 � f�r+s Mdb0 Alft�: ?~am MnaAor: l oeMly that 1 have pers"ly Impacted Ve$swaps disposes system at this address and that the into►mation reported below it true.,acaurirw and Comisleta as of the time of inapootlon The inspection was performed based an my training and experience in the proper tirmtkr•i sett ntal"toowree of on•sfte sowege dlspossl rr'sten+s. The system: passes _ Car4mortally►$sell Needs Further Etalluation By the Local Approving Authmlty Fails Y i)opmews sure' The System inspector shall submit a copy of this inspection report to the Appmring Authorky 180ard of Wealth Of DEPWtRM thirty("I dalre of oomordn9 this inspection. if the system :s a shwod eyotsm or has a design Royer of 10,000 gpd or greater,the inspactor encf the mystery+:owner SWI subrrrit to report to the apprapriate regional office of the Depo►trneffl of Eymrtronmentet Protecdor. The original should he awl to y>A*ya systmn owns►and oaplea seat to the buyer, if appueebls,end the approving sutharlty. NoTt'B AND COMMENTS RECEIVED F t b 2 9 2000 TOWN OF BARNSTABLE • HEALTH DEPT. revised 9/2/98 PmIof11 iAnt�d on R�.jt:bd hps 11JUMURFACE SNWAGF DWOM SYBiIVM WSPECT14M FDlttis PART A CMT>ftlC',AT10M joem6 ova 15-01 k-," l-a,Kai 01 M*-. MaN,n e z Caft,%f Inspection: jz 113100 NON CTM VJMMARY: Cheak A At C, ar ®: A. i1YSTM OASM: I have not found any IMormatica which indicator that any of the failure conditions described in 310 CMR 16.303 eias+t. Xny fedur4, erito not evaluated we Ind sated boiow. t:i9Mltdi>f86TS: __-- b. SYST1EA7 CWM, Dg AUV FASSSS: ._ Ore or more system components as described in the'ConditiorW Posit"&action need to be replaced or repaired. The syjmsm, upimn completion of the roplacarrtent :r repair, as approved by the board of Health,will pass. Indcaj:e yes, no,or not determined IY.If, or kD). Describe barb of date ruination' enstsnces. If "not determined",explttin why not. _ The septic tank is matel,u�ess the owner at opersrtor has dad the system Inspector with s copy of s GmHicote of Compliance(attached)indicsting that the Unk was In ad wldtln twenty 120)Veers prior to the date of+this in iwfl•on:or. the septle tank,whether or.not MOW,is aacke moral-V unsound, shows substantial InfWathm or enf irwRon, or tarik failure Is imminent. The system wig pass I an if the emisttlnS septic tank Is replaced with a complying se6.tic tank as approved by the bevel of health. ® Sewage hookup or M out or high state water level obeenred in the distribution box is due to broken or obstr.:ctod pllpets) or due to a brok veiled at uneven tSstribution box. The system wild pose ln&pectlon if iwhh approval of the Heard crt' Health). Woken papal&!ve replaced elrnxvetlon Is, d etribution box is levelbd or replaced The eyetam requirad.pure"more than fear timee is year dive to broken or obstructed pipotsl. The system will pass inspection if Iwfth approval of the board of HoShh): �. M-lrksn pipe(s)are ropleced aimtruction is removed reprised 9/2/98 npaeflt 9ISSURFACE SEWNK DISPOSAL BYSTIM OSPECTION FORM FART A CEIITIFICAT10p laorrrmradl Frepsrly Adr.as: �S'y/� Ra.GQ. �..q,� Ouwnw: /✓lar��n ez of btapaasalt� / 13/pp C. FIJIITNM EVALUATION E REQUM3 BY THE BOARD OF HEALTH: _ Condillorw exist wHeh require 01ftiw evaluation by the Board of Mesith in ordsr dsto►mine If the system Is failing to prlAw tf i, public health,safety and do sw4ronment. 1l SYSTEM V M.L PASS UIUM 11113ARD OF HEALTH DE'TfAaMIEs '0ORDAMM WFfH 310 CM 16.302 M Nb)THILT'IPME STrTFJN IS MOT FCArCT10MM N A MAMER WHICH WILL PROTECT PtXUX HEALTH AM SAFETY AND THE EMVI#H)Nlk*;*T: _ Cesspool or privy is within 60 fast of surf"* Casapool or privy is w thin 60 feet of a bor vegetated watland or a soft marsh. M SYSTUA t#PLL IT" TI a SOAARD OF HEALTH(AND PUBLIC IWAT'Elt SUPPLM.N ANY)DET9aRNM MT'TR SYSTM E FiMCfl00 Nfi M A ER 114AT PROTECTS TM PUBLIC HEALTH AND SAFETY AND THE®i1VI MRMT: The s hoe a sap�tic tw*end soil absorption system(S/IS),and the SAS Is within 100 feet of a surface ws'er supply or talbuta a surface water supply. _ The s tam has a 9"Ac tank and so"absorption system and the SAS Is within a Zone I of a public water supp't wMi. The ytte n has a sap,tk tank and sod absorption system enel the SAS is within SO feat of a private water su�ppIly wolf. T system has a sapide tank and sob sbaorpton system and the SAS is less then 100 feet but 50 feet or mare:from s Vega water supply!sap,uN*es a wad water analyeis far eoliform boetah and volatile orgenie com»ourwis Ind'IeaM.s VO:t*te won is*"from p",don from*het facility and the presence of ammonia nitrogen and nitrate nitrogen is*41101!to or h is gw fi ppm. Moo"used to deto-M distance _Ispproudmatioo net trail). 31 OT revised 9/2/98 p`3ot11 SIMURFACE UWA8E OISPOSAI SYSTM NSPWTWN FORM PART A CMT>!t(`,AT10(M(eetetb*ssd) f4eipsrtl/A�lrss*' /�y/ l�A.c t ��.r� OWN ?-. �k rrze Z Ouse dot bispeadan: ( t 3(Co 0. IMSTM FAGS: you must bwfeets etcher "Yea" or"Ate' III each of the Wowing: I haw determined that one of rrpwo of the following fallurs conditions oxist as described in 310 CMR 16.303. The Umis ion than dotermination is identMW belovr. The Board of Health should be contacted to detwmins what will be necessary to nortev,the faiwvt. yes No Backup of sewage irntr►facility or system component due to tin overlo or clopped SAS or cesspool. w Olochwgo or pending.rf effluent to the surface of the ground urfsee waters due to an overloaded or cluggled SAS;a cesspool. .� Static liquid Isvel in the distribution box show cud wrt dma to an overloaded or clogged SAS or cesspool, Liquid depth in oesspe+Ii is lase then 6" Avert je7oble volun►a is less than 1/2 day low. _ Rsq►fired pumping more then 4 tlmoo i last yoar eN to clogged or obstructed plpe(sl. �. Murnber of banes pum-,*d Any patton of the Soil A on System. cesspool or privy is below ow high groundwater elevation. Any portion of a CeesU or privy is within 100 fos4 of a Our water supply or tributary to a surface wrrtar s►,:,pply. Any portion of a oil"o privy is within a Zone I of a pubbc wed. ... Any poNo of a cassl:ool w privy is whhln 60 fast of a private water supply weN. Any n of a cees::,00i or ovy is laso•than 100 feet but greater than 60 feet from a pdv*to water au"Ay well wtth oo '—` water quality analysis. If the wail has been analyzed to be acceptable,attach copy of weft wrur on,irlysis far otiAonn bacteria,vatritils organic oorropounds,ammosda rdtrelen and nitrate nitrogen- E. UMM INTSM FALS: you M.Wst WWksta ai4har"y""at"No" to each of the foMewing. Tho fopowing criteria OWY to IMile systerrta{n oddldon to ft criteria The system swves a fasNky wish a design low of 10,000 greater(large System)end the systems Is a aignifice:at'rarest a�ps:bfic health and safety,and the an-Art►Inrnent beeauea one or s of the fogbowlrng eotndtdor+s exist: Yoe No the system is wl4hin ,i00 a surface drinking water supply age b whltin feet of a tdbutwy to a surface drinidng water supply i the system►Is I I In a n(troger►aenatdve eras(inteflrn INalihe*d Protection Ara*-fWPA)or a n%q*sd Zone.n of a;►abbe water I The~ar of operew of such syOum sirMl upgrade the system in saoordant:s with 310 CRAB 15.304I2)• Piww consult tlw local)relgicxnsl plflCs s4 the farfuvtlner in/o:madon. PW4otIt revised 9/2/98 IRMURFAiIF SEWAGE 0004MAL ZVSTDA WSPECTION FORM PART B «T Pmosirt/Ad*mw: Sy/ tracer owns►: 1&t+•Re ttZ iD o"of b"Peos)on: a- 4 13(ACC Check it the following hove been dons:Yaj must indlcste okher 'Yes"or "No" as:to each of the following: Yes No Y „r pumping information w.es provided by the owner.occupant, Or Board of health. None of the system components have boon pumped for as leaut two weeks and the system has been receiving m rmal flaw rotes during that porioti Large volumes of water have not been Introduced Into the system recently or as tart o: this Inspection. As busk plans hove been obtained and examined. Note If they are not available wlth MIA. ..d/ The facility or dwelMS was Inspected for signs of sewage back-up. _ The system does not mcsive non-aenkary or industrial waste ltow. Tito site was Inepaoted for signs of breftwA. i✓ „� Ao system components,excluding the Sall Absorptlon System,have boon located on the sits. The saptic tank mee►hoiss were uncovered,opened,and the interior of the septic tank wee inspected for ooldiNo t of balRal or tees,material of construction, dimensions,depth of kuid,depth of sludge,depth of scum. The she and Ioostion o-'the tail Absorption System on the site has boon determined based on: _d Exioting inf emosdon. Far example,plan at B.O-M, Qeterminad In the fksld(If any of the faiMuo critaria rehrod to Fart c is at issue,approximation of distance in wnae.eoplable) r. � (16.S021S96b91 ,1 The/edit owner land occupants,if diffwant from owner)wars provided with Information on the proper melr l ►ones 0;1 Subsurface Diaposoi S'reten+s• Par 8ofil revised 9/2/98 iUMURfACE SEWAG&DMVSAL SYSTEM MPECTIDN FOf1M PART C - iYs1'®YI UOFaRaAlbT900M plapwty Addveae: ownw- Ma 4 iwe Z OoSs d MAaelaa: a-J i 31 M BLOW OONDMCINS Das1 I r b a.p.d./bodroom. Numi'm of bedrooms(dosign):J Number of bodrooms(aewW):_t" Total on"sow fn Nuntlbor of ounont Midenta: ®orbW 1pIfWIN (yoo or net: Leuadry(Wale"oyeteml (yes Of naKit q If yes.separate inspecdon retluir,xd Laundry systom Ine,oeted Hes or no) Soeosnai ua(yes at nollcl_ f 33l �� �'l 07 I. wale*motor raedings,If aylrleMe(last tno yaw's usa"Ispd): Sump"IVM or no): Lost data of oetuponoy:iLft+ Type of ate: Deoign sow: and t S 15.2031 Rests of deelgn Aew Gree:w trap grew .(yes or WAuSvW Wye Woo" It present: (t#es or no)_, Nan-+tannery waste gad to the Tivis $system:(yes or no)— Water motor vas ,If available: Last dew of oc y: OT14 ( CNN) _.. 'oat det oeeupee►oy:... t�IAL Sf10+01t>lll1lTICEN P MPM piCORiDi end source of kvfnm, don:c� MTe CDv-zX System pumped as part of inspection: (yes or nal&_c If yes,vokano pumped: .—WOOM Ranson for pumping: �. TYM!Of SXfM A_ Septic tertic/dlsMbutlan boa/so' obsorplon system �._ Single cesspool Overflow aasspooi ShaMd system lyos or no) (if Ise,attach previous inspection rocords,If any) VA ToeMologY etc.Attach copy of up to date oWstion and'maintonanee contract T1ght Tank Copy of 0EP Approval Other APPROXNt ATE AM of aN compononto, date Installed(If known)and source of Information: Sw qp odepe detected when aMvInq M the site:(yes or no) i revised 9/2/96 1 USSWIFACE UWAOfi Ee1111POSAL GTO EM MPtECTUM FORIA PART C sTiTa�1 I�O�I111TI�M IeonWw4 �, OI'Ensp (cc WONAM 16l�R: Mocaft an she plan) u Depth"a*pub UL Matwkd Of 410 PVC other Isxplalnl OonatnlOdenc r,OOat iron a frolyiJ we"water Supply*-ON 0!-auction Une Dw"m q N Comments:leon*dm at;olnts.•ventlno,a vidones of ledlaim etc.) SWW.TAM ifeecte on sties PIMI t• DsPet below ate°'-� at4terioxplstnt Material of contra Lion:J.Ooft"—rristal_ Plbse�loss r„POQV�1 If is fo.18 m0 is Mp cerAi nod by Cm d icate of Compbsnce iYsslNe! Mudso dsptFt. d too Or bsftfs: 011mriso from top of*dos to itottom Of Oudst �' SOUM EMeknsss:L. Disteraee from top of 9"m t0 top of outhil tOa or btdfb: i/ Dlstalcee born bottom of scum to botttorn off o,�e�tl� N*or beM.:As �Ogll I�Plfaf�n0 1MM0 dOt�ffr@IOad:,Jai��+�•-- �ptrrlMrtaflta: irece<nanandatlen for Pun+pi�,condition,�f Irdst and outdst 1 Ns or bs Os. dsptir�of E� quiL v 4>�►ml�4o�!t invsrt, smietr�n lntar ty. saldar+0a of (faeats On dta OUNI Depth below Veda:— _pIs PolvathyllwA_OthOrlmxpQaln! -1001 Scram tldelct mess: 000 ert too or bOft; Distance from txsp Of scum to tap o Of olrt0at too Or bOBM: Platen"from bottom of Scum Dots*f last ptr"ft: COrsnrt�atta: Eft Qree� p�rnpinpy, ce�r�,of ktEat and outlet lass or rOffhs,®sp�ih of Rqcrld level in rotation to oartlOt Invart, stcvctur i� rtta i ,. _ reVised 9/2/98 PW7of11 • SUBSURFACE SURFACE SEWAGE DWOSAL 1MYST Al MPECTICIII F060A PAKT C l;9►S'!'oE� ATiL91114r pwpe ar A4169W. Own*P* moar+cndL 04"sal : at i YiMM'On}MOM TANK: (Tank i.iwat be pumped prior to, or at lams of, I tctF Ml (Waste ste an aft pion) Death below re".� MOW.el of oartnatlen:mooneeate-.-Awtel_,,,,Eiherylaas�' Mane ro"her explain) ------® ClmmrelAne: Dower flow AWm ptaeent Alarm level: ..�Aisar»in w ~.Yes ua No— Date of prevlo PUMO Cernmonts: toot~ of Inlet tee, a on m4 alarm and float awltahes,ate.! 90X-- nmmete en arts plan) .per of aqW level above mullet lnvart:,,4;u+I IAt Com+Tanb: Into If level M% dlstrl®udon It equal.ertlanee of solids cw a dame of IHkeps hltO or out f ) A--��►°�" fU!CHAflMt lleomw on aft 080 pumps in wmAdng o►dar:(Yee or Alarms In working order IYes or Comrwants: � � of pumps end e�urtetlancsa,ate.) lnmtm owAtion of pump olwmbw• .-._.�.—.—.- reiVi eel 9/2198 la�iatii I SLISS1lI9FACE SEWAGE DISPOSAL SYSTEM NSPECYIOM FORM PART C SYSTEM NAFORMATWU lorruim" ,fie Ad&sm 'Irv/ RA" Do*of btepaaSar✓01 (�t� sol<��►��At�.� (lacal*on alb plan,if possible;excavation not required,location rney be approximated by non-Intrusive methods) rf not kmated,oxPkim: Type: woo**pits•rr,r OW...J2, as*ehlnS ch*rrrbe►s,rr.trbs.:_.. Wee"trenches,number,lonrh:� loaohk►g field*,number,dlm*nsl xes: ovwfkrw eesspeol, VAld r•-- Alternatl *system: Name of Technolosv:. °m' d aoillcon'Stion of vs station, etc.) (note condition of sill ova of hydraeriie f*lure, ieY o1 pondng. ,+v/n .al , i i (locate an site plan) Numbiw and configuration --• 'teRtl►'taP at Resold to Not lnvwt: apth of sold*1"W., � depth of scum mrm: pimenalons of cesspool:,_, Mated-ds of co sunken: — -- re o*tdon of groundwabr u d as p P 6rt nee apection4��. — -- inflow(Cass awst be pump _r Cornmontt• Wwo,krvel of pending, candhion of magstation, etc.) (not*c of too,signs of hyd►arlic pilwat* (kraals on*It*pion) Mamilab of oonatwcdon• Olnwnokrra: _ Depot of sovda: Ce n*rrt*: c feNwe,level o g,f pondin condition of t�p en otati , etc.) Inoto N,condltlm of so of t revised 9/2/98 fhpr9ottt I 91JOSURFACE$&WAGE COPOS^L&TSTEibt WSP*C'T1OM FOW PART C sYSTll EEFOFMATWN 10000,0010 Ownw: MIA-m-e T� Defte1 AIL M)f OF UWASE DEPOISAt.SYSTUN: kvgtWo*es to st out two parrraw4m reference kmdmarks or bmehmerts ioe�ta sp weds wiN1M 100' (Loci"where puboc water supply comes into house! 17 I revised 9/2/98 of 11 ,r \ WA SIMACE SEWAGE OMPOSAL SrSTiM NSPECnM FORM PART C SYSTEM NPom"TON{oon110VAO Owm �fv1&4 ��y-z-�at� Dews of lnapereme. a_1 ,3 t oo NRCS Report nom Sop TtNe.— TyO46►depth to groundwater___. usazs Dow waeslte visittd Ob"mmnlon wens chocked Oroundwater depth: Shallow__ Moderate SITE EXAM slove surfece water Cheek Cepar shspow wells Fstimetnd Depth to Groundwow_!�.�Fsei please indloate ap the n►ethods used to daiorrnins Nigh Groundwater Elevation: 04teined haul Design Plans on record Observed Sato(Asut*q property, ot,semation hole, bssament suns+atc.) Osam�ined from local conMens Checked with local soard M health chosksd FEMA Maps Chocked puffon records Chaekd local excavators,lnstapers umW USOS Date Desorltw hdw you espAlished the Nigh 01 oundwater Elevadon. IV"be completed) J INCJ- r1o 4 revised 9/2/98 Pwilaili 1 N OF BARNSTABLE LOCATION / ' AC ('. L_ y9ii/-e SEWAGE # VILLAGE / h}5 0415 / /��� ASSESSOR'S MAP & LOTr9 — 3 INSTALLER'S NAME & PHONE NO. 31pfao T�PO/%9y/ SEPTIC TANK CAPACITY %36 O LEACHING FACILITY:(type) �)i b (size).2 -/060 NO. OF BEDROOMS��PRIVATE WELL OR � UBLIC WATER BUILDER OR OWNER `PCV/,� Cy fS i /l%l /i So' I / DATE PERMIT ISSUED: Cn DATE COMPLIANCE ISSUED: ;� �- '�S 7 VARIANCE GRANTED: Yes No II { f t E } 0 (Pi 1 7W4 37 �� Fx��...�` .. No................ _..... ..... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH1 6... .............OF.... .0.c .°` �__...._............ Appliration for Diopoottl 3 1ork Tonotrur#ion anti# o Construct or Repair an Individual Sewage i Application is hereby made for a Permit t C t t ( ) p ( ) 5 ge Disposal System at: ....:.. .y.. ..�C...... ----------------------------------------------- -----•... •--.. .. ....................................................... Location- So Addr,? or t o. --.-.-A..........e- .----------- ca 1� y F Zv Ownee 1�r Address a .............•...•--------------•••-----•........................•• •...................... Installer Address Type of Building Size Lot...A aA63._...Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ................................... Design Flow............ . ......... 2 gallons per person per day. Total daily flow__._�"4..7 ........................gallons. (� 7 s 6 �t' j � 3 it WSeptic Tank—Liquid capacity ..gallons Length,• ......_._... Width................ Diameter.______.___.... Depth_6...._...__. x Disposal Trench—No. ... .i_._....... Width................... Total Length.................... Total leaching area...................so. ft. ea **_5�. 3 Seepage Pit No...______._. - `-Diameter. _.. �f.. Depth below inlet._. .. Total leaching ar q Other Distribution box (� Dosing tank ( ) Z 1 errt`yS Date l_3"8S Percolation Test Results Performed by......... .......................t........._._._....... 1 1 ,.�tt ,tea Test Pit No. 1......R.....minutes per inch Depth of Test Pit.._..-_la......... Depth to ground wate...__:1�_��.� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------•----•--.-=-- 0 Description of Soil--- ... 0 . 1--•.-•-----•.. ................ ................. ............. ...............3 A`...-..�P-`-----•...M.�.�...��?....C��.c S1c � ..�,.-....�...�:!�, yvve U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by e board of lt�A A r-c 13 8S" Signed--�' n�` �......-•---I-•-----•-------•............................. ..... .........----.._.... � ......._. 1 _ Dat Application Approved By........ •---•- ------ e ............. Date Application Disapproved for, the following reasons---------------------------------------••--------------------------------------------------......_...----------- ••............................•--...........•--------•------`t, ..........•--•....----------------......------•-----.......-•---•-••--------•-•....--•-•••--•-.....---....----••. Date...----------- PermitNo..... ............................. Issued....................................................... Date No. Fizz ............... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ...........................OF.........................---...._..__. .................................................. ApvtIration for Disposal Works Tonstrur#ion "rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....:..........._--.............................................................................. ......---......._....-•-•-.....__....----•-•••--------••-----•----.....................-----•-•--• Location-Address or Lot No. .................................................................................................. -.........----....-----....---•-----..........._...........-•---.................................. Owner Address W Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms______________________________ __ _____Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building No. of ersons____________________________ Showers G.1 yP g ------•-•-•................. P ( ) — Cafeteria ( ) Q' Other fixtures ----------------------------------------------- ----------------- ---------------- •-------- •---------- W. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~I Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1________________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........................ a --••---------•---------•••--•------------------•---------....------•-••••-------•--•-•-•---------•--------..._........---.....---------...-••-•----........_. 0 Description of Soil........................................................................................................................................................................ "4 V .....------•-•••---•----------•-------•-•-•--•--•----------------------------------•••---------•••-••-•-----------••--•-------•-------------•--.....--------._...........-••••------..__...-----------_-- W ------------------------------------------•------------------------------------•--- --------------------•------------------------------------------........-----------------------------....._..._..--- U Nature of Repairs or Alterations—Answer when applicable. ---------------------------------------------•----------•--------------=-----------....---------------•----...-----------------------------•------------------......__..................._..........._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ................. , ate Application Approved By...................' -1''. ' �� =..............•-•-_----- ........1. _ 11 ...... Date Application Disapproved for the following reasons________________________________________________________________________________________________________________ ............. .......................•------•-•-------•--------...--••---•------------------..__........_..._....._....-----....--•--•--------•--------------•------•-•-------------•--••----------------- Date Permit No.___._ _,. .:.:_.L�__._ _ y-•..................... Issued_...------------- ------.._......-----------•----... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntifiratr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-•••••••-•--•••••-•--•-••-•--•-•------------•-----•-•--•----•----•------••-----••------•---------- ------------•---------=--------------------------••----•----•--...._•---•---•••-- --••--•-- Installer at................ 7!t-'M-l--.......=4_'e2c_�C=L Ln.-------•.( '<<..... . . ---------------------------------------------------------------- has been installed in accordance with the provisions of TI T IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... __. dated______________ _______________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.--------.. ............................... Inspector_ _ .: ------------------__--•--- THE COMMONWEALTH OF MASSACHUSETTS ---- -�"" BOARD OF HEALTH ............................................✓;.r...?..........OF........................................._..._..._.._._...._.__....::`__......._... No. ... FEE..,.";,... .......... Disposal Works Tonu#rudion "prrmit Permission is hereby granted------ -(�=_ A.x AI. -------------------•----...._..._.._..........---............_...--•----••------ to Construct f or Rep ) an Individual Sewagea Dispo System o... � e � - � � �'at N . .----- ! ..•------ ---•-C. ------....-... --- -------------------------------•------------...------------......--•---- Street as shown on the application for Disposal Works Construction Permit Now._If7:1Dated_____l faS------------- ----. , DATE............ Board of Health =--`-•----- -------%�_ .._.._ _. FORM 1255 A. M. SULKIN, INC., BOSTON - NA ID T +fit soft- _ ' , ... ; �lx-C� ��,�. �"� ,� �INr>c�tr��4 �F f5 F7' I { IllY.GESS 07"Ilfs' /S Tc> kl � 1 . 444 f'dP,6S 7-0:FEND IN 7-HE 5YSr,6 ,S/rAkl.. , . It 111111 till E CASr I1N OR scNPrf40 PVC. o. - _r...._..._. .. o` 0 @ 0 3 0 4 444 664 IC 7, , PIS71?1e lr l0N 90XES, • 4 NIN f9l � BE PE NE 'h`` �A✓P �EAC �' �� hG4�7t. SICK , �Eom 000 � ? r f� t a4P/IY S tz/o�EN C3R 1-I.�CC� HEED G ( o 0 0 - N S': REMOVE ,41,1, 41NSU1rA46k4r NATCRIAI. _ _ _� �3ENZQ TH 7'HE I1YY�"s'�'?" �"4,E�AT'/(3dVS - _, 0 O 0 CD rk rprEE ���� FOR A P16DANCE o, o ANv 45ACKFI4�, WITH CkAY fRF y 3,4NP,4NR GRAVE. H,4YIIVG A PERCOI 4TION _ 12 �__.�_._.;.._��.� .__._ YP/C,44 STD DX s NOT rO scA1,E _ T�'P/CAS.. Z,EACN/NC P/T �. r E ,��� .�8r �P Or HE,44,Tra 41sT A107F. P1SrR1BUT/OdV BOX ,M91ODD G,�4,4-. '� NOT TO SC,J,-E eS A10T1,rM',P Wi-1EA1 T11C k5YSTEM/5 N,E,4R O.3SE/�04TION- PITS ,�-llv-o�cZ-v SEPTIC ryaIVK BY ,: cQ����Z 10N,4NR tO/fir`r.f T©9.4Cffc141.1N6. TYPICA4/2r? C�'AL �,6MC TANf ,.. _ _ _ ..__ A�f,E�/G`AN PRECAST Q.�' EQC1.4�.. ?. UN,t,�`.SS O7'r�E"Rt�'IS�" NC�T£'f;Al,.�. .5YST�'�/ PE,RC4�,4T"IC�N h'.4T�" "- c:�l�i,��fir�l'.._. _ ._ - NOT 7"O 6C,44E - C0W,Pl1NENT5 SNAI,,1, &e INST.41,4,EP IN 5A ZV5 7,.97I4N5 Y `J.�s�s 8. Cc7N LG r1 NQTE: T,41V,Ar,5 REINFOR0 P 7-1-1904IGHOU 7' ACC0RR,,4NC, WI Ttr TI74,E" -Y OF�"I/E ST.4T F C3/�2ti1�T,4�BC6 BC)),4fs'!-' C.3F fVE.4.C.TH WITh/ ELECTRIC W-6-,PEP /-YMf F w1rH .�� - %' ,S4NIr,,41?Y COPE' ANR.4NY kOC,4L fOkES ENGINEZ',R ARROW ENGINE•ERlNG INC. STEE,�. RC>1 PS /N 70P� ,�'G�TTClM. N//IChr .4 Y f4Pl-14 Y• SATE 9 -1 -�,°� C0NCRE7"E !S 4,000 PSI T ,57 iVOT,E• ACC E-55 MArVI-/D.c.E5 ro ,5EPTIC TANK A NO /.EACH/NO P/TS TO B,6 E3LJIL7- UP 7O 4, FINISH GRAIrE' FINISH GR,4P5 o"' TANK FINISH Gf,4PE FIN/51-1 G,eADZ OVE,� E ,EY. = -?+ho E�.EY. "ito fIYEh' h 80" WK • 8, rr 7 +,25 a 0 ( o Q CD r�� o l� Of �14 ff.2 dA/Y _- 12SO G',44. /A , 4 +o pl I" U�' ° 0000 a S Q 0 o0-0 a v o dp C,QC/5HE.0 $TOdVE : REIIVFc G'EI� T4 Or 4 EYES, Q ��s � TE•. °°� 00000 o : -, �srlc rtN� 9� 017-0 0 a oCOD c �: /IVY= a4 ; u aOTTDM,OF PST � acN,.Nv (TD SE .LFV,61. �5rA'52.rE) L( ) L TYPICAL 5EWAC7F SYSTEM f� NOT 70 6CAL t r sECCT/DIY PdR E�, C:T APPRE','S .. ON'INC PIS TRICT rl-OOP HAZ,41'?� �'Dh'E L r7- �°ROP0 EP Z C4TI N OF Pl EZZIN , � ClL. nrU�ee R of IFPRool"s t Ex/sT. cddVTaUl -- -�- --�- --- E A6f R1%5 P Z SYSTEM /` �Il sSl�!s �Ell O�0/ti CJV/Pt ,-..�....-..• li'/1 C/ VV rp CONTOUR :. 1 GA4,1.ONS'P��,PERSON PeR d�.AY �� rxrsr �5/'CJ7" E�EV4�'!U/tii e*o /' POT- A ION _ . ;�EACNIIV� R�'f,7UIR�P RGfPOSEP S E-�{,�`Y T c�' C� , �: �, 1� .� r� .� .(w�'STOi��S Ml .1.:5) ��A, -^ •' ACNlNG P QY/PEP _ � ; ElfC04Arronl rES� ;, .4 ' '.�,/WANT' • ENGINEER ND PISP45,d.L C?,BSER�A7�'/CJN 7- �DDAC. ��z �T-f TeST IV 4dgRdf 'fl11 '1 : I GPI v - t � . �__ SCAB.E= PATE sh' ' "?" 7T ,N rr $ C> ti• g t , h�® C1 t k AS NOTEf,� TO 7-AZ- a x 2- &5 { ... _ • Y: P Y: AP�P 6Yr P ,4N IV - EY���' a•�fit.,�C S� t ,., �� �'►'�T � � f �