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HomeMy WebLinkAbout0034 TUPELO ROAD - Health 34 Tupelo Road,lV rstons Mills -77 i ,. 1 TOWN OF BARNSTABLE LOCATION ,) 6b SEWAGE # ` LAGS a&�kn< ASSESSOR'S MAP & LOT d u INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 60cg-kc. :6 e`r ® A 0 0 C 4 Aq 3 ®L ° �46 3 q 0 AC SS 0 � 64 LL �3 al � 3y �� Lp 4 " + TOWN OF BARNSTABLE 4-ATION C! U 0 R`• SEWAGE # Y:..LAGE ITV)• /V�il s ASSESSOR'S MAP & LOT e 7 a INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / Ufa 1 C.�W'�►S 4 size 7 f rQ� LEACHING FACILITY: (type) � SGb � � ) NO.OF BEDROOMS 3 BUILDER OR OWNER Or IS C 0�I PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a i 30 �� a S� 3 a �3 y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECT ION c, . , c o < CD �! 7i TITLE 5 t.h OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASS SSMFTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FO X- M PART A CERTIFICATION Property Address: 34 Tupelo Road Marston Mills. MA 02648 Owner's Name: Garrett Driscoll Owner's Address: Date of Inspection: October 14. 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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: _ ✓ . Passes Conditionally Passes Needdpfurther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: October 17. 2005 The system inspector shall su it 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 34 Tupelo Road Marston Mills, MA Owner: Garrett Driscoll Date of Inspection: October 14 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 34 Tupelo Road Marston Mills MA Owner: Garrett Driscoll Date of Inspection: October 14 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS.and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "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 I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 34 Tupelo Road Marstons Mills MA Owner: Garrett Driscoll Date of Inspection: October 14. 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: 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 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: 34 Tupelo Road Marston Mills, MA Owner: Garrett Driscoll Date of Inspection: October 14, 2005 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: 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) [310 CMR 15.302(3)(b)]. 5 I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 34 Tunelo Road Marstons Mills MA Owner: Garrett Driscoll Date of Inspection: October 14 2005 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Weekend use 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): Pumping Records GENERAL INFORMATION Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 1211 719 7-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 34 Tupelo Road Marston Mills MA Owner: Garrett Driscoll Date of Inspection: October 14 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _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: ✓ (locate on site plan) Depth below grade: 20" 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):certificate) (attach a copy of Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30". Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were Present. The li uid level was even with the outlet invert. There did not appear to be any signs of leaka e. Recommend um in . GREASE TRAP: None (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: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 i Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Tupelo Road Marston Mills MA Owner: Garrett Driscoll Date of Inspection: October 14 2005 TIGHT or HOLDING TANK: None (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: sallons/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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level and in normal condition. PUMP CHAMBER: None (locate on site plan) 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.): 8 I • Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ 34 Tupelo Road Marstons Mills MA Owner: Garrett Driscoll Date of Inspection: October 14 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 gal. chmnbers w/4'stone(per designplans) 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.): The leachin chmnbers were dry. There did not appear to be an signs o ailure. CESSPOOLS: None (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: None (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 4 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Tunelo Road Marston Mills MA Owner: Garrett Driscoll Date of Inspection: October 14 2005 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. L A A go j 1 3 a"" 16 a 3 Ss 3y Cl 10 4 �T Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Tupelo Road Marstons Mills, MA Owner: Garrett Driscoll Date of Inspection: October 14, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- 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: topographic and water contours mans Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+/ to Around water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION M � Z � F i r: y�e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 34 TUPELO MARSTONS MILLS, MA 02648 ®S 7 e? l S Owner's Name: SUSAN DRISCOLL Owner's Address: 34 TUPELO MARSTONS MILLS, MA 02648 Date of Inspection: 5/21/01 RECEIVED �1 Name of Inspector: (please print) . JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.. BOX 2119 TEATICKET,MA.02536 JUN 12001 Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNSTABLE HEALTH DEPT. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs FurW Evaluation by the Local Approving Authority Fails Inspector's Signature: I Date: 5/21/01 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this 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 THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****This report only describes;conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. TWo 5 Incrwrlinn Form 015/1OM Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 34 TUPELO MARSTONS MILLS, MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction•is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed NU apidiii`. i0A Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 TUPELO MARSTONS MILLS, MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 TUPELO MARSTONS MILLS,MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nla. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or preralgr .f ally lame SySt@n1 Fnll$Ifl@I'@E] a Siglli(iFant Chr(of under Section L or failed under Section b shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 34 TUPELO MARSTONS MILLS, MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components, excluding the SAS, located on site X _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 I , Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 34 TUPELO MARSTONS MILLS,MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,'soil absorption system _Single cesspool _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): n/a Approximate age of all components,date installed(if known)and source of information: JUNE 1998 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 34 TUPELO MARSTONS MILLS,MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7"W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 'i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 TUPELO MARSTONS MILLS,MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: _(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no) NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a u iPage9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 TUPELO MARSTONS MILLS, MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a 500 GALLON LEACHING leaching chambers, number: 2 CHAMBERS leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system n/a Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.): THE TWO DRY WELLS APPEAR TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE. , CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to iniet.invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 0 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 TUPELO MARSTONS MILLS, MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 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. Locate where public water supply enters the building. o A v r3 C U U n L i A� 3cy i�C 5 S in 1 Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 TUPELO MARSTONS MILLS, MA 02648 Owner: SUSAN DRISCOLL Date of Inspection: 5/21/01 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to detennine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET TOWN OF BARNSTABLE OCATION 2y T�c,41a Gr✓ SEWAGE # 2L -C► 3 VILLAGE ✓1l".r 6 ASSESSOR'S MAP & LOT - <: 'INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY :LEACHING FACILITY: (type) 1 . (size) Sad NO.OF BEDROOMS —� BUILDER OR OWNER 1;;t? _ ,Z AWJ .:..PERMITDATE: COMPLIANCE DATE: <` Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet `..::::'Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet :.'Furnished by TOWN_ OF BARNSTABLE ` LOCATION SEWAGE # VILLAGE �?AXs ASSESSOR'S MAP &LOT2e INSTALLER'S NAME&PHONE NO. JG ejA4--S / 77C_. �- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) //X (size) NO.OF BEDROOMS BUILDER OR OWNER ill. ' + - / ,C PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by j i �i��r:7� �S� •- .�'� � ��, �: _ ;© ,,� ,r ass. A I . �� No. Ll THE COMMONWEALTH OF MASSACHUSETTS'' Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Oigoear *pMem Comaruction Permit Application for a Permit to Construct( )Repair(V Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. t / / Owner's Name,Address and Tel.No. 10 /W / 4V of Assessor's Map/Parcel P r o s/�-�✓1L" Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7j `�') rJLt' (3oU ��c IJ A Type of Building: Dwelling No.of Bedrooms r of Size sq.ft. Garbage Grinder ta�� NCafeteria( ( ) Other Type of Building C r o. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 110 gallons per day. Calculated daily flow o gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) h S44 '2 — SV 09 a / C�cz wz tirJ w� !V 7 g- s � Date last inspected: Agreement: The undersigned agrees to ensure the construction and ma' tenance of the afore described on-site sewage disposal system in accordance with the provi ' ns of Title viron al Code and not to place the system in operation until a Certifi- cate of Compliance has be issued b a r Signed 7 Date Application Approved by Date f Application Disapproved for the following reasons Permit No. Date Issued ;r #• ,� *. � .�a,�a.,� �', . roll No. LIP Fee 'o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Yes ZippYication for Mizpaar *pgtem Congtruction 3permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System 0 Individual Components Location Address o of No. Owner's Name,Address and Tel.No. I FYI 14" iH'�rS !fit S[UI Assessor's Map/Parcel p 5,�,�e Installer's Name,Address,and Tel.,Io. Designer's Name,Address and Tel.No. 1 C d P d cy, 6 -Zm C Type of Building: r Dwelling No.of Bedrooms of Size sq.ft. Garbage Grinder( ) Other Type of Building 4* ';#VI (No.of Persons Showers( ) Cafeteria( ) Other Fixtures -- j Design Flow �/f Q M gallons per day. Calculated daily flow D gallons. Plan Date '"''' Number of sheets Revision Date ry F Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 17j,S>r (/ 2 - SQ a 6c ( x Date last inspected: Agreement: The undersigned agrees to ensure the construction and maiitenance of the afore described on-site sewage disposal system t in accordance with the provi ns of Title 5 vironm .al Code and not to place the system in operation until a Certifi- cate of Compliance has bee issued Signed Date �. pp Application Approved by F �` Date /l,r" �r Application Disapproved for the following reasons i t i Permit No. Date Issued ------------------------ ------------------ - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CAR- t at ,e O site S wage Disp 1 System Constructed( )Repaired (graded( ) Abandoned( )by cT 4 at 3� r has been constructed in accordance with the provisions of Tilde 5 and the for Disposal System Construction Permit No. 7 71 f3 dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date_ Inspector —— ———————————————————————————————— No. / 11-3 Fee �' 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1=igpo5ar *pgtem Congtruction Permit Permission is hereby granted to Construct )Re .' ( gr e( )Abandon System located at �41 X - and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this e t. "S Date: ��• / / Approved by - h L , 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) l , hereby certify that the application for disposal works construction permit signed by me dated �)�— - �' , concerning the property located at meets all of the following criteria: , /e There are no wetlands located within 100 feet of the proposed leaching facility V • There are no private wells within 150 feet of the proposed septic system V• There is no increase in flow and/or change in use proposed V' There are no variances requested or needed. ✓• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) a C S NED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted). q:health folder:cen t �S � Sbi �v 7 �lU S fj cd LOCATION 3t SEWAGE PERMIT NO. VILLAGESg INSTALLER' �I AME i ADDRESS - 1 L v �� r�l 11-��. s BUILDER OR OWNE'l DA T E PERMIT ISSUED DATE COMPLIANCE ISSUED (3 0' a Y� Fiz THE COMMONWEALTH OF MASSACHUSETTS O HEALTH ............/�!U.........OF................ tom, „�jP4 Applutttion for Kiapnsal 10orkii Tnnitrnstinn Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal sy --= ......_ �_` .�� ... .. ..!... �..1....1 s ...1t ------.....z .......... ......................... �„' ---- ti -A�dress o Lo No. . ...................... _ 1.n12�1` ..._ o Address Installer�•• Address Type of Building ize Lot..._(,,�iii . ......Sq. feet Dwelling—No. of Bedrooms...... ...................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ....._. No. of persons............................ Showers Q' � -----------••------•------------------------ --- ( ) — Cafeteria ( ) Otherfixtures _ ------------------•-----------------------•--•----•--•-----•------------•-•----------------... W Design Flow.................�,,a~ ........__..gallons per person aer dray. Total daily flow........... ................gallons. WSeptic Tank—Liquid capacit/fCO..gallons Length-__ ...�9..... Width../q.... Diameter................ Dept .�..._. x Disposal Trench— o..................... Width-(................. Total Length_...........P.......Total leaching area....................sq. ft. Seepage Pit N 16.o......./............. Diameter.._. .,S._._. Depth below inlet....-...:...... Total leaching area.26 ....sq. ft. z Other Distribution box `'' Percolation Test Resul s Performed by....._____. !�Y��J�.1&2� ..�— _�?�.....-. Date........................................ W Test Pit No. 1................mmutes per inch Depth of Test Pit:_____11.. Depth to ground water........................ LZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W ................................ ... ... .... ...4..__..._..... ...._-_- -------•------------------------------- O Description of Soil...........-`�-----P.......�--CtA.1D ..��._.. �`�,C. •---- -- ---- ----------------•--•---------- V ---------- 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 iITI.% 5 of the State San tar Codes. ersigned further agrees not to place the system in operation until a Certificate of Complianerhas been issued by oar o �. Signe -------------------- -- ----------- -------.----- _� . ... -le Application Approved By.._�___._ _._�1Gt11�(._ ' `. d.....dL/ Date Application Disapproved for the following reasons:-------•-------•--.......---•---------------------------------•---------------••--------------------------•-•--- .......................................... .......-•----.......-------•-...---•--.•-----._......_____..----..--.----------------.-- b-----•--.-_---.......------...--•--.•--_.__. Date Permit No. ........... --- Issu = -------•--------------- ���� Date .....':::........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...._-_....l.4g' .lry.............OF�`�.r� t �............ .....-.-.----_-.--.-----.--.----------- Appliration for Bispvii l orkii Tvastrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System, fI I ...... .. 12 �5 �(��1 ........... on-Address or Lot�i� c...... ,1^r v\'T'r� -•-- --!•i-!....................... Ow e A re s .!4v Installer � Address Type of Building Size Lot..Z—... 5�6....Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers a YP g ------•--------------------- P ( ) •— Cafeteria ( ) dOther fixtures -----•-------------------------------------------------•••----•-•-------------------•-----•---._._.... W Design Flow............�_`e5....................gallons per person per day. Total dai�y flow...___.,,, _0.............._.....gallons. WSeptic Tank—Liquid capacat/t _.gallons Length . __.____ Width__'7r_.._0.... Diameter................ Depth ............ x Disposal Trench—No..................... Width___�.._��.._.... Total Length........ _�----- Total leaching area....................sq. ft. Seepage Pit No......../.......... Diameter.._..$.. .._. Depth below inlet..... ......... Total leaching area._~'00....sq. ft. Z Other Distribution box ( ) tank ( ) Percolation Test Results Performed ....... Date........................................ ,.1 Test Pit No. 1 -,__-minutes per inch Depth of Test Pit.....a........... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x •-- ------------- ----- -----••••-• ...-..----- O Description of Soil------. `-----_. C py.'.'S/ ..._. �.� SLS�.--•------------ - ----- ... is �. w ----•-----------------------------------------------------------------------------------------------------------------------------•----------------------------------------------------..............-- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------------•--•----------•--•-•-•-.....-•------•-------•--•••••..-------------------------------•----•-----•----------•-•-••----------------------------........---•.------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Com lia een issued)y the f Signe .......................... .` •.--. .....-------- ........................ ... Date Application Approved By................ •�— Date Application Disapproved for the following reasons:-------•----------------------------------------------------•----------------------•----•----••-----•--_-•-•- ................•---.....---•----•----•---------------------••-----------....-•--•------•--•--•---------.._...-......----•-----------------------....----------------------------------------•--••------- Date Permit No........................................................... Issued. • .-----------------=-- ...._..............---------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... .. ...........:OF............ ...... Cnrrtifiratr n To ttpliattrr T I TO ER. Y That the Individual Sewage Disposal System constructed L)ISr Repaired ( ) •.. .� by yl� - ......................................................... ... nstal"r has been installed in accordance with tt�isions of TIT T' 5s�of T e State Sanitary Code as described in the application for Disposal Works Construction Permit No.- ......r-.- _:__._..._. dated___.'........................................... THE ISSUANCE OF`THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE., SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH OF.............. . ! ..................................... 3l� FEE......................... Permission is hereby granted..... �..... ?'.._........................................................................ to Construct ( r Repair ( ) an Individual) Sewage Dis sal S Stem�!,'� at No................ r.......�, _JX44 1`'A'-<............4.. :' + Street as shown on the application for Disposal Works Construction Per 't No......VZ ed ....................................... •-- t.. ....-'----------•-------•--•--•------------- lth DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t..t0 CaAt'7�:.G.G.�• i-;-GZi�'U� � Y f� TA"V. = 33c:>,, (r5G % s 4.-q s� 6.P. ^. z n -1 SPC'<,d,t_ _�i"(- - c��,�, t�G� GAL , � ' 41•f3 f _ f SF )4 2..5 .3 = G.P.t). BW=041 Aze- = CE�D Sr5•. t .b I! \ ti .zo ► i `," ( Uk C G r INV PEI �y r .77i.:s.;�.:..u:.S, r.ixa♦ ,,�'"piY�-` :•r J,� 1000 Ti4 iuo'. (w, LeAni4 1 F,T W t rO A 'a T j40 �.1 v SG A.Lfc � CGtz't't F=-� T'►-IAT` T(-1i~.. %4Z ly t_t�t,1 �i�U�C�L�lS �</1►F '�'t#L= 'j'1 D:% L!1J�; -TO w Q C": C k�5`t�'�'t tom` , / t�.? u S +��. l 1 , �♦�!-�A Gt t 4�- RC G I S CC,: .D L.A,b.i G SU 2v Y�14 i ice.-, QOT LA;:GC7 Ut•J A.W tiJ♦,C��:1:.�C W+ Wit){:�lC�♦{ x! 'CiIC: L�Ft ��z�ri 4-�GWI.0 AppL_1 e:&"- r,. e'.k.r C.C_ U`:rGc`> 6 t)e:ist-.c":Mc�4t� LOT L1Na�� �� 60isi106 V