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HomeMy WebLinkAbout0062 RUSSELLS PATH - Health 62 Russells PathIo - �� Marstons Mills P / A =_02-098 1 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Russells Path Property Address I Laurinda Kersey Owner Owner's Name R�1 information is :c required for every Marstons Mills Ma 02648 12/11/2015 page. City/Town State Zip Code Date of Inspection ti.7'7 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. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 Further77:z7712/11/2015 hority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ��#�V s t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 62 Russells Path Marstons Mills is served by a Title V septic system consisting of a 1000 gallons septic tank, distribution box and a 1000 gallon precast leach pit. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 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 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Russells Path Property Address Laurinda Kersey Owner Owners Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water 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 '/2 day flow t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2014=29,000 total = 79 gpd 2015=23,000 total =63 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 10/2015 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,•�''p 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 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 9/23/1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection 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 62 Russells Path, Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 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" Scum thickness 3° 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 6mensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be cleaned now and again every 2 years for routine maintenance. Water level was even with outlet, inlet and outlet baffles were intact. Tank was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not(located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 62 Russells Path M SVer Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was video inspected from distribution box and was found to have only a few inches of standing water with a stain line 2'from the inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration —Depth to of liquid to inlet invert p p q. Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: Z hand-sketch in the area below ❑ drawing attached separately t5ins-3/13 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 62 Russells Path Property Address Laurinda Kersey Owner Owners Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i t ` t TA N k� O r �3 i - kZ _ A•3 LeAcK Phr 7q )3-Y 6 t5ins•3/13 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 , 62 Russells Path Property Address Laurinda Kersey Owner Owners Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 62 Russells Path Property Address Laurinda Kersey Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/11/2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -\ COMMONWEALTH OF MASSACHUSETTS ExECUTLVE OFFICE'OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMEN ON SEP 2 0 2002 TOWN O B NSTABLE HLTTITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Fi 2 'AyS-f1 lli /IN �ry lWays los s 4 A07, DtP6y-1 ' ! Owner's Name: Osai, C/o 4` Owner's Address: G7 sf e 1 js i§ Date of Inspection: $ --/ - vz MAP �Z Name of Inspector: lease print) Tn�n - Ila h" PARCEL P (P Company Name:_ jy4" 4af 5 A�g 'tioe LOT Mailing Address: $T --- - -- /� ti , &/Zs 44, 02 Fig/ Telephone Number: sUS 77>11 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.aon site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 1.5.340 of Title 5(310 CMR 15.000). The system: _/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT- OR`YOI UNTARVASSESSAQ,NTS,�; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued] •` ` Property Address: 6Z 4 sells 4/x Owner• - k© , ;4"a Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complet"M otSeao®,D� A. System Passes: 1`'— I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass-'section need to be replaced or repaired:-The,system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.,, Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. r. 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 fail=is im`minera;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 Com 1'3'M6e indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break;oul or high static water level in the district-Non:box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. P System will ass i n yf with "' Y approval of Board of Health): broken pipe(s)am replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will .., pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 ' Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS # SUBSURFACE SEWAGE DI$PO$AL:SYSTEM INSPECTION FORM PART A; CERTIFICATION—(continued) Property Address: Owner: 4rO— Cyafc. Date of Inspection: 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 ismithin 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 front a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOTE FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL°SYSTEM:INSPECTION FOR1l.,!' PART,A CERTIFICATION.77(coniinued) as PropertyAddress: 6 �-f p ww�� Owner: Date of Inspection: 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 _r/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool __L,- Liquid depth in cesspool is less than 6"below invert or available volume is less than %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. V 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 fhan'S0'feet from a-private water supply well with no acceptable water quality analysis. [This syste"rim passes if thtivell water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fallam criteria are triggered.A copy of the analysis must be attached to this form.] N (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply _ — the system is located in a nitrogen sensitive area•(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well a If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large,system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART B 'CHECKLIST Property Address: 6 A4sse/A P14 i MPr S v c Owner: (9hi Date of Inspection: 8—/b- 0 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 L/ 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) V, _ 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 jSAS)on the site has been determined based on: Yes no r/"_ Existing information.For example,a plan at the Board of Health. _ 4,- Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION.FORM,—NOT FOR"yOI,UNTARWASSESSMEN-M.., SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM.. PART.0 SYSTEM.'INFORMATION Property Address: b Z Aosv//s 10-o i� y/crr,1 o..lr Ar Owner: �nn Graf Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual):. -- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x;Yof bedrooms): 3 0 Number of current residents: 1. Does residence have a garbage grinder(yes or no): A✓o Is laundry on a separate sewage system(yes or no):a/o [if yes separate inspection required] Laundry system inspected(yes or no):)6!!!s Seasonal use: (yes or no): Ala Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: c u 1 i1/ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: d wn a� Was system pumped as part of the inspection(yes or no): If yes, volume pumped: logo allons--How was quantity pumped determined? Reason for pumping: /Nunn L.,. ✓. Q %� << ' 7aNlc TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yet,attach previous inspection records,if any) Innovative/Alternative technology.Attat:h'a copy of the current operation,and maintenance contract to be ob_tained 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: ,, ,r -13 JoC,; Aelln r I Were sewage odors detected when arriving at the site(yes or no): /Vv 6 . Page 7 of 11 OFFICIAL INSPECTION FORK'NOT.FOR*VOLUNTARY. ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL'SYSTEM INSPECTION FORM '"PART C SYSTEM INFORMATION(continued) Pro perty ert Address: 6.2 ;Pwssej1$ 417 C/ as oh t 91/"Llfr' Owner: Uh L CvuL Date of Inspection: . BUILDING SEWER(locate on site plan). . Depth below grade: 20 Materials of construction: cast iron 40 PVC `' 'other(explain): Distance from private water supply well or ion Ime: Comments(on condition of joints,venting,evidence of leakage,etc.): - SEPTIC TANK:_(locate on site plan) :. •"t` '. ;',,. _': _ Depth below grade: Material of construction:.. concrete_metal_fiberglass_polyethylene , :.. other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of . certificate) Dimensions: S x S-' Sludge depth: J 2 " Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ": Distance from top of scum to top of outlet tee or baffle:. Distance from bottom of scum to bottom of outlet tee or baffle: 9,Or" How were dimensions determined: Comments(on pumping recommendations,inlet a d outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,-evidence of.leakage,etc.): , I19tY1 GREASE TRAP:_(locate on site plan) _... _ Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and.'outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 :OFFICIAL INSPECTION.FORM NOT:Ft}R VQIJUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM.INSPECTION FORM .SYSTEM INFORMATION(continued) Property Address: 2 RussL��r Mals oaf771,77s . Owner: &1 rCa' Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inpec;ion)(lrstate ar{site plan) Depth below grade: Material of construction: concrete metal, fiberglass Polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: vt5 (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. : l/ ...Gchr. Ziar �otr1l'. bo��cv - ra- � No s���n 'biltA' n� NO c� 3'i+hid C'4,�ryavJr d°ror-► v � g�A PUMP CHAMBER: (locate on siteplan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc k • _ 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) Property Address: A t� if�1u vs wu � Owner: Date of Inspection: "B—/6—02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explainwhy: C�«col NO� i i G' �.. O n Ty Pleaching 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.): 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 or 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.): 9 Page 10 of I I OFFICIAL INSPECTION FORM-NO. .FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART:.0 . SYSTEM INFORMATION(continued) Property Address: Owner:_`rbh� 74r. Date of Inspection: 7 6 01 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.1.Locate where public water supply enters the building. V� 33' 7 ' 37 i fb.., 71 • 2 D 3� . I O 10. page 11 of 11 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTA RY ASSESSMENTS SUBSURFACES WAGE DI SPOSAL ISP. �. OSAL SYSTE M MI NSPECTION. ., M FORM :,.. PART C< . SYSTEM INFORMATION(continued) Property Address: 62 �uss1)ls �� ,� Owner: 1 CIc./ Date of Inspection: SITE EXAM Slope. Surface water Check cellar - Shallow wells Estimated depth to ground water,3a:sffeet Please indicate(check)all methods used to determine the high ground water elevation: J 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: tis Checked with local excavators,installers-(attach documenta ion) Accessed USGS database-explain: You must describe how you established the high/groundwater elevati�ol: G e� U raH•-+vt ��fGG.: �L✓,v//a�! ($r`n WLt d it n .. 11 ASSESSOR'S MAP NO. - PARCEL LOCATION SEWAGE PERMIT NO. V I L L A G E -_--� i 1NSTA LLER'S NAME" i * ID.pRES'S r sq. c . 1 UIL,e ��' .. 'OR OWNER. -- DST E PERMIT 1S SUED i j DATE COMPLIANCE ISSUED A ASSESSOR'S MAP NO.a��� PARCEL LOCATION SEWAGE PERMIT NO. Z-o••f- -* 7 s i t S P�3�1 + VILLAGE 'cmm w, L r INSTALLER'S NAME -9 AbDRES"i „4-o i3 c-old . S U I L D E R OR OWNER DATE PERMIT ISSUED � � � PAT E COMPLIANCE ISSUED ' 231 o� ASSESSORS MAP NO: No. ..`.�S(AICEL NO.: Fxs...... p. THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH a� v l �./...............oF...........:. wa � -.. ... Appliratijan for Biiipmal Works Tnnitrnr#ilan Vanfit Application is hereby made for a Permit to Construct ( ) or Repair ( -) an Individual Sewage Disposal System : ,� 6 `� . : ------ / ocat n-Address or Lot No. .... .�J _. ....��.0 - ��-•--- ----..� .�...._... .. y— .�.a.......-- .. ss Installer Address Type of Building ••�� Size Lot__Z __ ....Sq. feet.-. U Dwelling—No. of Bedrooms j....v................................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building .A1�'..1 ............. No. of persons.....---..--................ Showers ( ,) — Cafeteria ( )- fl, Other fixtures ------------------------------------------------------ W Design Flow----.-.-V. ..........:...................gallons per person per day. Total daily flow..--.� ..................--......gallons. WSeptic Tank—Liquid capacity. .gallons Length.- :.7.. Width.--.'.1.-.ZDiameter................ Depth............ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No....Cl!!!----- Diameter..... _2....... Depth below inlet......Z.:.......... Total leaching area..2.4�..'.--S..sq. ft. Z Other Distribution box ( ) Dosin nn Percolation Test Results Performed b ....... -.t.... . -- 't' .................................. Date....��.:-._� ..-..CY., a Y - -- ,� Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ •-••------•-----------------------••----------......---......---•----------------------...................................................................... 0 Description of Soil.........................................................:.............................................................................................................. x W ---------------------------•-----------------------------------------------------------•---...•-------•--------------------------------•---------------------------------------------------------....-- VNature of Repairs or Alterations—Answer when applicable............................................................................................... ..------••-•------------------------------•-----------•--•-•------•---.......--------......-------•----.......----------------------•--•------............----------------....----------•--•--....••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'L U 5 of the State Sanitary Code—.The undersigned further agrees not to pl e the system in operation until a Certificate of Compliance has bee * su d the board of hea h. 12 Signed --- ---- _..._ Dat ApplicationApproved By................................................ ...... .•.... -•..... • ............... .- ..- .2 -...._.. Date Application Disapproved for the following reasons----- -------------------------•------------•----------------------------------•---------------------......_.._ ..........•-------------•-•••----...-----•--•-----•----------•---•....---•••---...........................---•--------.......------------------•.....------------------------•---.... -•---....----- Date PermitNo......................................................... Issued....................................................... No......................._ F$s............._.... ...._ THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH ......................................OF.......... �'^���!?..J�.....�..... ...-----..................... Appliration for Disposal Works Tonstrnrtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System _ --�-- ........ ..1�'..... �`.J C. ®��.... Li1........ .................. .... .......... ........ scat' n•Address / or Lot o. _ 49,00...5... :UG . ......7/ ..... .... ✓........:... .. (� /J G ner G.......�� _.. E G �..f.—G��.� .:...........•--...........•........... a .. ........ -- ................�.... --- Installer Address Type of Building Size Lot...G.:a r! ....Sq. feet Dwelling—No. of Bedrooms.._............:................::..Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building - '..g................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other_fixtures .........-•••.................................. Design Flow....._.I..�i..............................gallons per person ger day. Total daily flow__._. ....................gallons. Septic Tank—Liquid capacity.e Q° .gallons Length...---:..2... Width.... ._. Diameter________________ Dept h...k......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area..___..........._._sq. ft. 3 Seepage Pit No....lJ!" ..... Diameter..._ z....... Depth below inlet................ Total leaching area..2.1.Z..sq. ft. z Other Distribution box ( ) Dosing Percolation Test Results Performed b ....... ......... ...1r,1�' ,(................................... Date----��.'-_ .� Test 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........................................................................................................................................................................ W •-----....---•-- ....................................................................................................................................................................................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to pl e the ,ystem in operation until a Certificate of Compliance has bTsuthe board of heath.�'/Signed.... J .......•----_--- ....__... e c Application Approved By...................................... ..... ....... ....... _ ..........._. .----.......... IDate Application Disapproved for the following reaso ........................................................................................___ ..............•-•-----•-••--••--••-----•--------•-••-•--••-•----.............................-----------•-•-•--......---•--......--------••---•-----••-----•---••-••--••-------•-------•--•---------•--- Date PermitNo.................................................... Issued......................................................-- Date l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT....... ..........OF.........&Ke��2 DH (Intif irate of Tompliann THIS TO CERTIFY, That the Ind v' ual S a Disposalem constructed ((�or Repaired ( ) by............ . ........ .......... .'_ �.� ..... Z ..:..S L?h^..:.� �.�t.....................................-....- Installer at.......................................... .........................•--•-------•--•--•-••--------r -•---------•--------------•-----•--------•-•--•--......--•-- -------------•------ has been installed in accordance with the provisions of TITLE Qf The State Sanitary Code s de ribed in the application for Disposal Works Construction Permit No....... e �J..f dated...... ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUN9119N SATISFACTORY. DATE................:..........' �'�`a 1�?- -----• --......... Inspector.....�i"�.....................•------------...----........---....----..... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH ..............oF......... /s_ :.: ........................... No.... . ?.'.`.-� Fn........................ Disposal Works Tono#.ruution Wrufit Permission is hereby granted.........................�`SC7 11. /A Cd .1...-•-••---...........-•--•-............ to Construct (� or Repair ( ) an Individual Sewage Disposal System 94A Ill atNo................:.. -• Lt3._.�-..- '� �s. ..........P.h••(h...-•-••---•- •---•---••-•---........-•-•------.............---•--•- Street as shown on the application for Disposal Works Construction Permit No..... ��_g ,Dated..............)--SL................ ............. •........... ........ } Zi _ --........-----•--..............•--••-h DATE..................... ...............................•----_..... FORM 1255 A. M. SULKIN, INC., BOSTON t •� r a i Y - Upper Cape Engineering P.O. BOX 616, EAST SANDWICH, MASSACHUSETTS 02537 (617)362-6281 E i F i Sept 23, 86 Board of Health Town of Barnstable Main Street , Hyannis RE; LOT 74 Russells Path Dear Sir For your edification , clarification and elucidation , the septic system on lot 74, was installed in accordance to the design submitted by this office . s Thank ou John Jacobi -. ..... . ..., � � F.:. .r,,,•.+ ��"nr."-`'`r+'y�-nr�P'7!'^'FtT�• ,.. - _ __-- _�" __ _- - - -- _ _ ... srrrpr•�•.--.- -. - ram„ .�.ww.,�„�,...,....r..�.w,e...... s...r.......a�..r..s+.ra+�Mr� �.a.,M,a.rrw«.w....w.��...o.« r .vnrf+..�+i+i+Mw+.+s•+....r.Axaii.,..rr.s.��-,�..r..r.ew�.+i..rw...,------ FL �- . ,TOP of rouNanTIOKJ se/ CONcREr4- COVER / CONC4467E COV095 (A RrS�R ntaF - `rni t �� VPITCH t g' pER F7 a r/ EL .ZX�VE"T \ t,JVERT F INVERt �r 5(?T)C TANK S y� Dr i v / Box 't i X3 - _.._ INJE�rq .• � E L L ErL yTt 00 1 UA N7 PROF LE OF oll `�A`A SE PT IC S YST EM SOIL LOG GENERAL MOTES DAT - NUMF R �c r � � TkST r�►<t } DESIGN DATA ,�'(,�N,BEk OF C�EDRaJMs TOTAL. f,C QW f'D BOTTOM LCAClH/NG ARE A ii3 ,SIDE LEACHIA1G AREA S� Sa FT GARBA C E D/,5/crSA 4, Alt) _ SOg i,�IGceasE ;'ETA L 1—,EA CH/NC ,A)P,"A '� SQ. FT \ /�4rEre ENc 10W7ETErD PERCU,4ATi9N RATS moo• .Z -TTktr- 6, x w AAO F COTE (/f>Rr�l�ceE �FQ Fo,P v✓c-�t c To 6,F- o,v •4mT 8/ 8 � e _• _a PREP/4 RE'O d3 y y _/ C�1P� �AIGINLERII�G If t , t�� §�+�r •., P o. 130,�' (o/�O .�. SANL�Irv"/C,'� �`1�' s SCALE DATE DRAV//V BY APP'D $y �. -�.�:`. .g•+wfs"+r.a..•..•,.......-......,r..r..a..w.-.....,...,.:....-.w+..�.,......r.••.w..w.•w....«.a.y......++........«�. .+.-r.,....,......� ....�r......,+._.....�..+................ ..........+.�.�_.-.�....�,�...�.....-.w.,..«+��....,.�........,......., '1 �'.+f'r f !/'�✓ r r Y� .( (.. ( r, r r r , f /r'Li i 1 ! 1 r f.,r r ! 1 / r r r / r! . <. . . , - .._,. • - ._ _ ..,+�.'