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0251 REGENCY DRIVE - Health
251 Regency Drive t Marstons Mills A= 064— 042 k Commonwealth of Massachusetts o&q' OyoZ- �n :. Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r .............. 251 Regency Drive Property Address J Edward Schwarm Owner Owner's Name information is required for every Marstons Mills ✓ Ma. 02648 06-16-2019 f page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms �j�� f 3 91 L.{ on the computer, 1 use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails r 06-16-2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has a H-20 1000 gallon septic tank and a H-10 D-Box feeding a precast leaching pit. At the time of the inspection the leaching was dry. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. ` a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form <1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The se system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or Y p more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Regency Drive V� Property Address Edward Schwarm Owner Owners Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. CityTTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static Liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of.Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts �n Title 5 Official Inspection Form iSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: I 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 plus GPD + Description: I Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No 11 If yes, discharges to: I Is laundry on a separate sewage system? (Include laundry system inspection ! information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No I Seasonal use? ❑ Yes ® No i Water meter readings, if available (last 2 years usage (gpd)): Detail: In 2018 39,000 gallons were used and in 2017 43,000 gallons were used. I I Sum um p pump? ❑ Yes ® No 1 Last date of occupancy: June 2018 Date I 1 I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form r ti Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is . Marstons Mills Ma. 02648 06-16-2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: j Type of Establishment: I Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis.of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): i I 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: I gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 l i I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1985 1 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 36°feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information cont. y (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard H-20 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 7" Distance from top of scum to top of outlet tee or baffle 4" 11 Distance from bottom of scum to bottom of outlet tee or baffle 11 How were dimensions determined? 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.): I recommend the new owner have the tank pumped and cleaned and then put the septic tank on a maint. plan with a local septic pumping co. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 9 p Y ry c V!% 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Regency Drive u, Property Address f Edward Schwarm 1 Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ^I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Regency Drive ' Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): I Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: one ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 , Commonwealth of Massachusetts Title, 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection the leaching pit was dry. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I r Commonwealth of Massachusetts p Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Vol untary'Assessments w 'y 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is Marstons Mills required for every Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ' m� J 70 _ 9-5 Z ' r 3�? (D = 27 Z t5ine.doc•rev.6116 _ Page 15 of 17 Title 5 Official Inspection fomt Subawfece Sewage Disposal System• Commonwealth of Massachusetts Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope i ® Surface water , ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feet 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 t ® 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: I augered a hole at a lower elevation and I shot it with a transit to show four plus feet of seperation. I i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp"doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 251 Regency Drive Property Address Edward Schwarm Owner Owner's Name information is required for every Marstons Mills Ma. 02648 06-16-2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I 362-4541 926 main street yarmouth mass. 02675 down cape eagineefing civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys March 29, 1984 site planning John Kelley Barnstable Board of Health sewage system Barnstable Town Hall designs Hyannis, MA 02601 RE: Plan #84-239 inspections Lot #16, Regency Drive, Marstons Mills, MA permits Dear Mr. Kelley: It is permissable to use a leach pit which is kt deeper,,than the one specified in the subject plan. Very truly yours, Arne H. yOja� Down Cape Engineering AHO/nmw P I COP� =�?�'� fly'° I s;��,� ,. SACI� iET�S J �- .T ExECUT OFFICE OF Er��RONM EN�u AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM Q Oy PART A CERTIFICATION 3 r� Property Address: c sue• 3,3i�'� =� _ Owner's Name: —Pak.,CM Owner's Address: << C - Date of Inspection: Name of Inspector:(ple se print) at ►e r ► Lti• ' t ! Company Name:_Aa i tad lh.3Qec{�or�S Mailing Address:—P-,I I' C)a4q Telephone Number: . 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: r Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 1. LJDate: 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address flow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page-2 o: 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) Property Address: ,Q,c,pl-y (rflla- r1 1P Owner- r4� Date of Inspection: l0 j aj (o 5T Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V I have-not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of H will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.I of determined"please explain. The septic tank is metal and over 20 years old*or the septic tank( er metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure ent System will pass inspection if the existing tank is replaced with a complying septic tank as approved the Board of Health. *A metal septic tank will pass inspection if it is structurally so 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 o1 High static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or ven distribution box.System will pass inspection if(with approval of Board of Health): brok pipe(s)azeieplaced ob is removed stri an box is Ieueled or replaced ND explain: The system require pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with rovaI of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL,INSPE-C-IrION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: o? Owner: Date of Inspection: O O C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiurther evaluation by the Board of Health in order t etermine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance wi 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public he 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 vegetate wetland or a salt marsh Z. System will fail unless the Board of Health an Public Water Supplier,if any)determines that the system is functioning in a manner that protects t e public health,safety and environment; _ The system has a septic tank and soil orption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a ce water supply. _ The system has a septic tank an AS and the SAS is within a zone I of a public water supply. The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well** ethod used to determine distance "*This system passes if a well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile o anic compounds indicates that the well is free from pollution from that facility and the presence of nia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are "ggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL.INSPECTION FOIE—NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DMOSAL SYSTEM INSPECTION FORM PART.A. CERTIFICATION'(continued) Property Address: rt,K Owner: .S�W o.c in )Date of Inspection: LO(-@j-A(( D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for III inspections: Yes No 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 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'/z day flow o� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped a_ 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. o� Any portion of a cesspool or privy is within a Zone I 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.fnis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic,compauNds 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.] Ab (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 ' a design flow of 10,000 gpd to 15,000 YYoou must indicate either"yes"or"no"to each of the folio (The following criteria apply to large systems in additi the criteria above) yes no — _ the system is within 400 feet of . urface drinking water supply — _ the system is within 200 et of a tributary to a surface drinking water supply _ the system is I in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a pu c water supply well If you have answer es"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D ove the large system has failed.The owner or operator of any large system considered a significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CNIR 15.304.The sy em 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;-���j/ �V,� Owner. �b IO.t Date of Inspection: Check if the following have been done_You must indicate`eyes"or"no"as to each of the following: Yes No 4X— — 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? X— _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) 4 _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? 4— _ 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 o the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? 1 _ Was the facility owner(and occupants if different from owner)provided with information on the proper m intenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)j310 CUR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:.�& Owner LA oti.f IAA Date of Inspection: 0 D b FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: I I0 gpd x#of bedrooms): 330 Number of current residents: Z) Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no) [if yes separate inspection required] Laundry system inspected es or no):A)Q Seasonal use:(yes or no):00 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:�7/a COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank presen es or no}:_ Non-sanitary waste discharged a Title 5 system(yes or no):_ Water meter readings,if a•✓ ble: Last date of occupancy/ e: OTHER(descri GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): LJV 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,datstalled(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):{ti0 6 Page 7 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSES-SMEN'TS SUBSURFACE-SEW-AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: '? r R ��•� Owner: Date of Inspection: BUILDING SEWER(locate on site plan) . t� Depth below grade: Materials of construction:_cast iron _A_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade:U W Material of construction: Y concrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance certificate) (yes or no):_(attach a copy of Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler u Scum thickness: Distance from top of scum to top of outlet tee or baffle: t� t Distance from bottom of scum to bottom of outlet tee or bWe: 14 How were dimensions determined: M-2G.S Ur tc}i Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relate I outlet invert,evidence of leakage,etc.): t 'foL b CA i AA-. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:`concrete_metal fibergl _polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet a or baffle: Distance from bottom of scum to botto of outlet tee or baffle: Date of last pumping: Comments(on pumping recomm dations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evid ce of leakage,etc.): 7 Pages ofli OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: c"2 n`-,( Owner. S I.$)O4t0 Date of Inspection: TIGHT or BOLDING TANK: (tank must be pumped at ' inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass,polyethylene . other(explain): Dimensions: Capacity: -gall Design Flow: Q ons/day Alarm present(yes or no): Alarm level: Al working order(yes or no): Date of last pumping: Comments(condition alarm and float switches;etc.): DISTRIBUTION SOX:V(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: a vt LA 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.): `7_L�.� box WG5 PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of pum ber,condition of pumps and appurtenances,etc.): � - 8 Page 9 of I I OFFICIAL LINSPECTION FORM—NOT FOR VOLUNTARY ASSESSME NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A C `v{ 11__ Q G Owner: ie R�OLr Date of Inspection: 61) tpkkp�_ SOIL ABSORPTION SYSTEM(SAS): (Iocate on site plan,excavation not required) If SAS not located explain why: Type _jam leaching pits,number- 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 �'6 t'CGG�s'� i V Y'roV CESSPOOLS: (cesspool must be pumped asp of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundw r inflow(yes or no): Comments(note co ition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (Iocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condi n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc_): 9 Page 10 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD } PART C SYSTEM INFORMATION(continued) Property Address: 2 c i J t Owner.� acvn Date of Inspection: (^n ( S 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. To �wLa� IOU a7 37 (00 3(l i OFF'.FCL4,L INSPEC`"ION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a Dfivv— Owner:�_ f Date of Inspection: t (31 a k jg5- SITE EXAM Slope Le Q--> Surface water WO Check cellar Yes Shallow wells V"v Estimated depth to ground water.02 O feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Yl LOCATION SEWAGE PERAII N0. 0 F. VILLAGE ��C�S i�►US 0��� �S I N S T A LLEIt's NAME i ADDRESS e B U I L D E R OR OWNER /�. ® I�DA/�1/� DATE PERMIT ISSUED 1 / JV5 DATE COMPLIANCE ISSUED TS J v X 0 1°° THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ` .�. ................OF..... .......0.�:Y1S�`�.b`e ..-.......--........-.......... Appliratinn for Disposal Works Tonstrudinn Prrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. ...... ............._.__....._.......-- --------------------------------------- •--•-•- ............_----- ......... Owner Address a .... .......... .......................----............._... ............................................. Installer Address 00 q Type of Building � Size Lot.�'5,...............S feet �-. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............... No. of persons............_.............. Showers W YP g -•-•-----•--- P ( ) — Cafeteria ( ) QOther fixtures -.............-................----------------------•-•-•-•---......_.................... W Design Flow.........5 5........................gallons per person 4y. Total $ow---......33 0......__............ to WSeptic Tank—Liquid capacity.IRO...gallons Length. _.. Width:... ._1.2... Diameter................ Depth.. .�- Disposal Trench—No............... Widtht..... -�*-_.... Total Length Total leaching area........____.......s ft. ►�+ .. gt ........I... g q• Seepage Pit No........I............ Diameter.... __e_.W, Depth below inlet....e :. Total leaching area. 3n _D.n t- Z Other Distribution box Dosing tank ( ) �-' �\t Vr�a5 .� 'S.:.t..........••.......... Date._...... . ........... Percolation Test Results Performed by...._1:........ � Test Pit No. 1....L.z-.minutes per inch Depth of Test Pit...A n..ii.... Depth to ground water..hOr!--0-4 .-. 44 Test Pit No. 2................ inch Depth of Test Pit.... ....... Depth to ground water....eV\C.QO►�}et'e� a"►�+' O�r �2...Y.�.._� ....S...v.. .S....S�....e.a...;... S,Z��_ DSO .............C....c.�.. ......................................................... -S ...........�.. e ... `` ......----•---•......... ......... ........._...---•......... ................-•-•--•-----..................-•---............... ---••-- V �O Description of Soil W x V 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:I':LZ 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. ... ;� `.. . . v Application Approved By..--•-- ...t..............•----•-•-•-•-•-.......-•-•------._ ..--- ..y� �--•---.. 1 Date Application Disapproved for the following reasons:-----•................................•-----...........----------............................................ ................•---•--•••-•-•........•--•---•------•...----......................--•-----••--•-----•............-•-•----•-••---....................---......---........--------................_......� Date Permit No.......42...S ........ 5...-•--•..................... Issued _ ----.......!_. ...�....�5. �j ...... Date t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` oW.YI.........._....OF... 5 Appliration for Bispnattl Workii Tomitrurtion Permit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at Lot Location-Address or Lot No. ................_...._.._`..I .^M-----•--•--...----------....---------- .......... ---........---....;._............................................................_. Owner - n a 1�..... s� ............................................ `....: .....].... a v Address, }.__....__........... W Installer _ ........................................................ . . •..•••• ! I d Address Type of Building r Size Lot.45...... feet ►-� Dwelling—No. of Bedrooms......--------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aa Other—Type of Building ........................•-•- No. .ofi ersons�`-"'...._................. Showers YP g �, �� s pt_ ( ) —.Cafeteria ( ) dOther fixtures ...........:...... '...............----..I...."....I-••-------•--------.....-•--•------•------.............--......................------........ Design Flow.................................::'.._gallons per person day. Total dai y flow_. ___..i. _................I............. to g Wr Septic Tank—Liquid:capacity AS? ...gallons Length. Z... WidthL���;:�:'. Diameter______ _____ Depth_'_- x Disposal Trench—No..................... Width;..... _.._.._..._._ Total Length....... �. Total leaching area. ............... ft. Seepage Pit No..._.._�............ Diameter_.1�..� : Depth below inlet._'4_.e :. Total leaching area..!I.sq-ft-G)D Z Other Distribution,box O. w Dosin tank0-4 ( ) Percolation Test Results Performed by.� :.Ov.m�•S..-E...`...5:..�_: .• Date.9�.18AB4....._._... ,. 4 Test Pit No. 1.._.�-_.minutes per inch Depth of Test Pit...1 c S?..;........ Depth to ground water..n�n�...._ f� Test Pit No. 2................minutes per inch Depth of Test Pit elnco....... ea p p _ Depth to ground water_ a . . 0 Se_e_ ��,e \a. , Description of Soil..-r; :.......... .... .....--- ......... ......_.........._....,.........---------------•-- C7 - SZ S.i 5o i 1 S 2 " - \SO '' 1M@ Goat'Se SgY1 W ......---••-•-•---•.-•-•...................... ..... .---......_..._._.. ........................--•-- .............-----..........._.............. .........a.......... x ........----•-•....--.••-•---••-•••......-•----...-••--•------------------•-••-•--•-••.....--•--••.--------••----.......•.... .........--...--..._.......:. U Nature of Repairs or Alterations—Answer when applicable..................... ...................................:................................. .......... --•------•--•-------------•---•-•--------------•-----.......--•-.........-- .............. -•-••--••-•--- -•----• ......----•-••.....••••-•--•---- •-------•-•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in,accordance with the provisions of TITLEE 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. igned..... . . ` ------------------ ---- Application Approved B . l . - D ........ . � Application Disapproved for the following reasons------------------•------•-----...............---------.......----•-------------.....------••-•--•-••-•.......... ...............................................••----••-----.....:•••--•--...--•-----......-•--•------..........................................._...........----•......--•---....--••............- ..._ Permit No..... 7 1..................:......... Issued.- . .........-- ............-- Due THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH f ........................I............./..O F............................................................... ................. CIrrtifiratr of TI-Implianr TEAS IS TO VCR(IFY, That the Individual Sewage Disposal'System constructed ( or Repairedby.... . aA A_%, ..._.. �.0, ..-• ... ---------:_s.........................................._.......... Installer at.. s.�`z.l� . ........ 7j.�1.. 1C�5'�D:l� S -1A.k �5 ..1.....__1 t............................... has been installed in accordance with the provisions of TI of T State Sanitar Co16, as described in the application for Disposal Works Constructin Permit No...... datedy..... . � .�.`...t`................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........a................... 5.........._................... Inspector--•--• ................ ... -- _ �. _-— ------ - ... .,,. _— _ ._... _. _ _—.� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N .M �CCJ ..........................................OF..................................................................................... F .. P Dispimi nr s Tonstrnrtiurt Permit a Permission is �g reby granted..._ •-4h�-................ .•----..._.......-•-...--••••..................... .•••....... ... ....... ............ ............ to Construct ( � Qr Pepair ( ) an Individual Sewag4l)isposal S. stem at No..._...r.�a_ I `...._..._.1,� 1l� -...............1_v� !(C.- � �5.: ...---.,J�-..i_5.....----•-----.. �?�...:.� ._.._.._._.. t Street as shown on the application for Disposal Works Construction Permit No... ���_ Dated......... . -`�-i................. Y Board of Health DATE.............................................................................. AsBuilt Page 1 of 1 LOCATION SEWAGE PERM I NO. ;k0�/6 2f��1�C �' >21 U F VILLAGE ii�r�S �S I N S T A LLER'S NAME A ADDRESS GUILDER OR OWNER R. D '�oovirr� DATE PERMIT ISSUED ca� DATE COMPLIANCE I S 5 U E D �S v J x o l 100 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=064042&seq=1 5/15/2019 t,x ' BLNc.�u,�ak• ,,`r SECTION - SEWAGE '� t'o•'•`'r , �"I� � ApPpoy, sQotA 1 wa.�.�.. Lputcx=44:Q-0-- -SEPTIC TANK - - "D"BOX - - LEACH TQP OF FON + �� (MSL)* "2"OF 111TO V2" .� 4 WASHED STONE `/ �� \ .t T `� IN•, M1 OUT• > 4 0 �.Q �� - IN.+ OUT IN. t8� 2V t,+/ 'P a%QL G .• Z f \ tC SEPTIC �.� I • ���`e'lJ'1 p - ELEV. Z*Y` TANK k y=- - iL• f ..�o Q! LJ / l(O ELEV. ELEV. ELEV. ELEV. ELEV. -a �L/ / I �MI^l \ t /a�CC AoC �NG� tu WASHED STONE \ a 111k TEST HOLE LOG Q >. v / � TEST BY. T.l�•CVMA!`a CZ. . G�FFC�OM ` 10. X - �1 TEST DATE 1 I>a _ WITNESS « 3 BEDROOM HOUSE T.H. 1 T.H. 2 ; % `�► � DESIGN li ELEV. # ELEV SM µ© Q NO DISPOSER DISPOSER toy mop PERC RATE Z MIN/IN. • FLOW RATE 330(GAL./DAY) SEPTIC TANK ,"'S3a X (t•s)= {\vacs / c REO'D SEPTIC TANK SIZE 4CCQ q'. LEACH FACILITY - Q$ '� �•� ,� m.a.d triad SIDE WALL to tz 4 =NZS117.51 _ -514.'7 G/D. �O w'r� Cowc�c. BOTTOM' 1Q3 C' ! )=' g S1 ) "t B' C TOTAL 2oq.2bi:'. USE. LEACHING two ..-1E3�' \fie► . " '14"� i� � ..i �_ +o �• NO WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) \ \ 1.DATUM(MSL)*TAKEN FROM____A�A,94.r....................QUADRANGLE MAP 6�J r AO 2.MUNICIPAL WATER_---_-._-_---_�!��............__AVAILABLE �� OF 4fq5 tj� � \ �� ij- 3:PIPE PITCHa'A"PER FOOT �7at.f,�9T N��j P►pt S�Q ,C�Q� sQC �F o • 4.DESIGN LOADING FOR ALL PRECAST UNITS: AASHO- T tC 44 yG O ARNE H. DISTANCE AS CERTIFIED S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. ARNE �!` • 6.PIPE'JOINTS SHALL BE MADE WATER TIGHT H. OJAlJ4 "•.� 1 • 4�j ( 11 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. 6 OJALA CIVIL ' SITE ` PLAN STATE ENVIRONMENTAL CODE TITLE 5 " '4!26348 No. 30M , LOCUS: 2G.t,.t1)ir.ac_ l7t�+.ram REG. l ENGINEER- REF: down Cape Q#I PREPARED FOR: . f3G W A�C� Ca._ �t.1�►WI?��1w CIVIL ENGINEERS ------ `----- �- — LAND SURVEYORS /•�BOARD OF HEALTH � REG.LAND SURVEYOR (EXISTING)......... \Jf� N:�Tf�r LE MA 92'�iA SCALE p 2. CONTOURS (PROPOSED)-O-O-O-O- APPROVED DATE DA E v4 ~ -" �