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HomeMy WebLinkAbout0033 VIOLA LANE - Health 3 3 -Viola Lane Marstons Mills :oaf 0 nA_nn� \ Commonwealth of Massachusetts 0413 - Ob(?—00 3 Title 5 Official Inspection Form lI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . .� � 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 = page. City/Town State Zip Code Date of Inspection t ' -af �.3 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. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 05-05-2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 I Commonwealth of Massachusetts �n Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding two leaching chambers. At the time of the inspection there were no visible signs of past hydraulic failure. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The.system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r� Commonwealth of Massachusetts Title 5 Official Inspection Form ' I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. 33 Viola Lane V� Property Address Monica Williams Trust Owner Owner's Name information is Marstons Mills MA. 02648 04-30-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under.Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ �i Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 r Commonwealth of Massachusetts 111� Title 5 Official Inspection Form . '- lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 plus GPD Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: In 2018-44,000 gallons were used and in 2017-41,000 gallons used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts ,1� Title 5 Official Inspection Form '10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: new leaching was installed on 03-13-2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 39"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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v � 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 30"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: standard H-10 1000 gallon Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 3„ Distance from top of scum to top of outlet tee or baffle 41' Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend the new owner have the septic tank pumped and cleaned. The I recommend the owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form <b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 33 Viola Lane V Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or,Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material.of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �� .. ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is Marstons Mills MA 02648 04-30-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form +- I1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. 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 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ iinnovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts r� 4. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is Marstons Mills MA 02648 04-30-2019 required for every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible signs of past hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �. -. Title 5 Official Inspection Form i1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties.to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARNSTABLE LOCATION 3 �O 4 SEWAGE# VILLAG s70A�> *41jr 5 ASSESSOR'S MAP&LOTV3-6-3 INSTALLER'S NAME&PHONE NO. P,4�,,-rO.i t l- SEPTIC TANK CAPACITY /000 G 7 LEACHING FACILITY:(type) (size) A/t y NO.OF BEDROOMS BUILDER OR OWNER—D e-J va► e RS PERMTTDATE: J 2,7—6 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 �33 L.J 0 C Ln- A-r Z 3 - q V3 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c, 33 Viola Lane V Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feetfeet 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: augered a hole at a lower elevation and I shot it with a transit to show 4 plus feet of seperation. r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 33 Viola Lane Property Address Monica Williams Trust Owner Owner's Name information is required for every Marstons Mills MA 02648 04-30-2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included r Fey r� o F S A-s I V t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ter. 7 TOWN OF BARNSTABLE L06.-kTION — ��®L �� SEWAGE # 10 9� VILLAGE 4210/4s *$111 Ls ASSESSOR'S MAP & LOTg3-6 " INSTALLER'S NAME&PHONE NO. _P4,ZrOlt.c- C X yo�r �30-y SEPTIC TANK CAPACITY 1,900 6 4 LEACHING FACILITY: (type) `!�0 f (size) A�y NO. OF BEDROOMS BUILDER OR OWNER ,l1 ej 1LXlit i t/25 PERMIT DATE: -7 e/,7 a,,� 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 i -1 0 %s Ar, 13 t � J__j ` TOWN OF BARNSTABLE LOCATION 32 LJ+"c�'m LC1 SEWAGE # VILL"AGE—M=1=5 M i 11 S ASSESSOR'S MAP & LOT��`��06 3 INSTALLER'S NAME&PHONE NO. 5' e-D+t''_ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS_ BUILDER OR OWNER PERMPTDATE: 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 of 113-5�i No. OW6 i49 J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH bIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZppYication for Migpool *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.—33 v j pc-,9 L-N Owner's Name,Address and Tel.No. i � L 1.?CSL7u�a tir An sr~ ���x� 3� v�C�`� l r� �,�ns7a�► r-'�t,c.� Assessor's Map/Parcel 22!9 � 7 Installer's pName,Address,and Tel.No.�I�SrAiLF, ac AV-ftd esigner's Name,Address and Tel.No. 3, D of fLG ASS' P.© 80,� %Va9 'f�0xi:JV-LZ y70 o Z.B -93cm. 1`'l14 obi 5&3 Type of Building: Dwelling No.of Bedrooms Lot Size. 1 9sq.ft. Garbage Grinder( ) Other Type of Building 3106US T-0, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3.3o gallons per day. Calculated daily flow 3 3 4 gallons. Plan Date A-a® - O to Number of sheets i Revision Date Title Size of Septic Tank C7 0 I Type of S.A.S. :2 5 cxn� A kA - Description of Soil f3 " ' 101' S 16 Yl - 3 Ll t► C. Z411 Ir Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 e Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has beenOfBoar of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ■.as....�.--- --- -- P No. 6 ­-6q4 ..j o Fee X". THE.—COMMONWEALTH OF MASSACHUSETTS Entered in computer: A _.1 Yes r- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS j 01ppYfcat on for Oigaaf 6p.5tem Cowaruction Permit J, Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.33 woc q t ^/ Owner's Name,Address and Tel.No. &17&1e_ /,jG5"Un/Ed '' 33 v1&-4 4N- ^f4as� n4/1,c,S Assessor's Map/Parcel M Q2Sr� M/�$ t7- 1!!9 V- 6 -3 Installer's Name,Address,and Tel.No.PA15raf4c, DC AV ATl esigner's Name,Address and Tel.No. T. D v�w ASS jx P.O gv+t 17 �9 1�R,CSTA9A� ►?o c.►.o�62t=r6t,D wA� ob- 4-Lb -q3o� 141N—ic%-Av 0--% , iv1►A 50e' 56,3 - RqL/ Type of Building: Dwelling No.of Bedrooms 3 Lot Size 10,E 0 8 sq.ft. Garbage Grinder( ) Other Type of Building Sl Wb( FAM No.of Persons Showers( ) Cafeteria( ) Other Fixtures r' Design Flow 3 3 O gallons per day. Calculated daily flow 33 d gallons. Plan Date 'a ' O(o Number of sheets Revision Date% Title Size of Septic Tank 10®Q Q I Type of S.A.S. a 5 00 o 1 G 14 A LA R Description of Soil A © ' I d rt Q 1 b" - 3 y ri C. 34 t1 — /I& rr Nature of Repairs or Alterations(Answer when applicable) RCP 1_ACZ,.) F A I LZ D SA5 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system , in accordance with the provisions of Title 5,pfAe Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ' sue yoar2i of Health. �} Signed Date d Application Approved by `. Date Application Disapproved fo'r the following reasons Permit No. 69 L Date Issued 3 6 --------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 11 Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage,Disposal System Constructed ( I�) Repaired( )Upgraded ( ) Abandoned( )by PAS T'OV-16 IZ,>(,C,A yAT 1 0-0 at L&) M iA R.STr ay,.- IM 1 Ll_ ha been constructed in acc rdance r i with the provisions of Title 5 and the for Disposal System Construction Permit No. —DC06 dated 3��3 Irfr Installer lPA'Z5T �1/`�"'("l Designer 3. IL The issuance of this pe it shall 'ot be construed as a guarantee that th sc�y em ' ti`�cti�on as<designed. Date �� InspectoK—A \� �3-- ----� `mot No. ® 1 f Fee G THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogai *pgtem Construction permit Permission is hereby granted to Construct(,Repair( )Upgrade( )Abandon( ) System located at 3.3 V I at-A t..N MIA[.-Ky;-�!VN u--� 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 competed within three years of the dCb p Date:_, � b Approve I Town of Barnstable �oSHE.rp�L Regulatory Services Thomas F.Geiler,Director snxxs�na�e. a Public Health Division Thomas McKean,Director 200 lain Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 23 Designer: 4eke,1 M°L rl' Installer: P#- -r ar�.r,, Address: .d, Address: ��,, �,4-ry✓✓I v 1G6� /1!�'_p-ZS3 �o n.�'s%n eyG� �-,�_ On_ _��`" O P,4s Adt,r was issued a permit to install a (date) ' / (installer) septic system at �3 V 10tA LA,5 based on a design drawn by (address) dated 6 (designer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 1 a' lateral relocation of the SAS or any vertical relocation of any component of the.septic system)but in accordance with State&Local Re . ations. Plan revision or certified as-built by designer to follow. 1PARR M4 1_YE N (Ihstalldixs Si afore) r r o. 1140 Y �G1STE�� SgNI TARS P� a(Designere's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNS ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CAR ARE RECEIVED BY THE.$ARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 15.220: Preparation of Plans and Specifications The plans and specifications for every on-site system shall be prepared as follows: (1) Every system shall be designed by a Massachusetts Registered Professional Engineer or assachusetts Registered Sanitarian provided that such Sanitarian shall not design a s tem designed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203. Any other agent of the owner,may prepare plans for the repair of a system.designed to discharge not more than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided they are reviewed by a Massachusetts Registered Sanitarian and approved by the approving rau rity; (2) Every plan submitted for approval must be dated and bear the stamp and signature of the designer, Every plan for a new system or plan for the upgrade or expansion of an existing system which requires a variance to a property line setback distance, must.aiso reference a plan which bears the stamp and signature of a Massachusetts Licensed Land Surveyor in - dance with M.G.L. c: 112, § 81D; (4) Every plan for a system shall be of suitable scale(one inch=40 feet or fewer for plot plans and one inch = 20 feet or fewer for details of system components) and shall include e tion of: (a) the legal boundaries of the facility to be served; y (b) the holder and location of any easements appurtenant to or which could impact the s stem; (c) the location of the all dwelling(s)or building(s)existing and proposed on the facility and identification of those to be served by the system; (d) --the'location of existing or proposed impervious areas, including driveways and parking areas; f(e) location and dimensions of the system (including reserve area); (f) system design calculations,including design daily sewage flow,septic tank capacity /(required and provided); soil absorption system capacity (required and'provided); and �v�W'hether system is designed for garbage grinder, (g) North arrow and existing and proposed contours; (h) location and log of deep observation hole tests including the date of test, existing lWYO f grade elevations marked on each test, and the names of the representative of the approving authority and soil evaluator; (i) location and results of percolation tests including the sate of test and the names of Tam: e� resentative of the approving authority and soil evaluator, rs d certification number of the Soil Evaluator of record; (k) cation of every water supply,public and private, 1. within 400 feet of the proposed system location in the case of surface water sppplies and gravel packed public water supply wells, Z2. within 250 feet of the proposed system location in the case:of tubular public water supply wells, and 3. within 150 feet of the.proposed system location in the case of private water supply wells; — ) location of any surface waters of the Commonwealth, rivers, bordering vegetated wetlands, salt marshes, inland or coastal banks, regulatory floodway, velocity zone, surface water supplies,tributaries to surface water supplies,certified vernal pools,private water supplies or suction lines, gravel packed or tubular public water supply wells, subsurface drains, leaching catch basins,or dry wells; and the location of any nitrogen ,t/'/� sensitive area identified in 310 CMR 15.215 within which portions of the proposed l v stem are located. (m) location of water lines and other subsurface utilities on the facility; observed and adjusted ground-water elevation in the vicinity of the system; o a complete profile of the system; (p) a note on the plan listing all variances to the provisions of 310 CUR 15.000 sought LVAK in conjunction with the plan; /(q) . the location and elevation of one benchmark within 50 to 75 feet of the facility which is not subject to d#location or loss during construction on the facility; (r) when dosing is'proposed, complete design and specification of the dosing system proposed including but not limited to dosing chamber capacity (required and provided), pump curves and specifications, number of dosing cycles and depth per cycle; (s) when a Recirculating Sand Filter or equivalent alternative technology is required or roposed,a complete plan and specification for the system,including a hydraulic profile; t a locus plan,to show the location of the facility including the nearest existing street; the street number and lot number, if any, of the facility; and v) the materials of construction.and the specifications of the system. i Notice: This Form is To Be Used For the Repair Of Failed • Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, �,.7of/K//,0 0 0YLe`:� ,hereby certify that the engineered plan signed by me dated Z-2 D -o G ,concerning the property located at 33 �9 L -/J�Jd�s T /Y/��� meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) J'Z . o B) G.W.Elevation 43 +adjustment for high G.W. 2- = 1 . , o DIFFERENCE BETWEEN A and B 3 7 - SIGNED : PAS DATE: 2-Zo -b G NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc Town of Barnstable �, do o [PlyRegulatory Services co Thomas F. Geiler,Director BAMSrnst.�. • �� A 9 1�g Public Health Division �fn�" Thomas McKean,Director • 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Sewage Permit# 1-0a4 2-03 Assessor's Map\Parcel 024,035 Designer: 000-PAP 6UOSSMA► ) Installer: n6tnt, hhaY1 .Tnc-. Address: " FALM• 89TS RO, 04 Address: 5,p X _11 &LMQtq; HA 02540 8d*v5t,1145 Mills 0,649 On - Z1- 04 1 l't C-04 S-rc was issued a permit to install a (date) (installer) septic system at 14" SAOr UIT h.IEWTbW ) J based`on a design drawn by (address) (am dated 63-03~0 4 (designer) ✓ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of-the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by desi er to follow. �ZH OF stal 's lgnatuie NORMAN , b GROSSMAN N No. 12705 CIVIL a A�Ur GlSTEF�F� (Designer'sSignature) (Affix er p Here) �4 . PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc i TOWN OF BARNSTABLE LOCATION -3 L �� SEWAGE # PILLAGE .In ff 6. 410-2 P;kJ- l s ASSESSOR'S,MAP & LOTq.7`6 W 3 INSTALLER'S NAME&PHONE NO. P4 5T�°+y. t✓r ��� SEPTIC TANK CAPACITY "/000 G9 ' LEACHING FACILITY: (type) '/a (size)• r*Z h AV NO. OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: _®0 ®4 , COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of.Leaching Facility Feet Private Water Supply Welland 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 3 Lf3 49 it .. ..__ :....-...- •' ':: A SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■'Complete items 1,2,and 3.Also complete A.,�ignature item 4 if Restricted Delivery is desired. k ` ❑Agent ■ Print your name and address on the reverse X 50J. �Ll et✓, Addressee so that we can return the card to you. YReceived by(Printed Name) C.�te Deliv ry ■ Attach this card to the back of the mailpiece, L or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: ZI"W-S -� If YES,enter delivey,°address below: ❑No APR p 3 ?pps 3; Service Type 1 1 1 Q� ^ 0�� ❑ M.-illr nI^ Certified 'Express Mail ❑ Registered ❑ Return ceipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7 0 0'5� 116 0 0 0 0 0 0191 i 115 4 (Transfer from service label) ±'' I` ' /— PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • PUBLIC HEALTH DWISION TOWN OF BARNSTABLE 3 200 MAIN STREET HYANNIS, MASSACHUSETTS 02511 Co I � I I I Ln OFFICIAL r9 Postage $ •3 s��t\11S Mq O C3 Certified Fee �6'p O (Endorsement Endow ent RequiFee red) .d )(� i AMR 3 l3 Restricted Delivery Fee f.-D (Endorsement Required) / r=1 Total Postage&Fees $ `SPS / u7 p Se�nTo l� A t IVo53 n --POpo Box No. Q � City,State ZJP+4 Certified Mail Provides:o A mailing receipt (esian911)Zoozeunr'00eeu410jsd o A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or PriorityMailo. a Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. e For an additional fee a Retdm Receipt may be requested to provide proof of delivery.To obtain Rehum Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery". ' e If a postmark on the Certified Mail receipt is desired,please present the arti- cie at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. q Town of Barnstable pF tHE Tp� .Regulatory Services * BARNSfABLE, Thomas F. Geiler, Director MASS. 6'639. ,•� Public Health Division ArFD��A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 23, 2006 Mr&Mrs Marc Deslauries 33 Viola Lane Marstons Mills, MA 02649 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located, 33 Viola Lane,Marstons Mills, MA,was last inspected on February 11, 2006,by, Shane Syr ala, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: System is in hydraulic failure You have 2 years from the date of the system failure to bring the system.into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. ZBARNSTABic HEALTH EPARTMENT A. , R.S., C.H.O. Agent of the Board of Health r TH OF MASSACHU ,per AL ETTS S�-\ COMMONWEALTH y� EXECUTIVE OFFICE OF ENVIRONMENTALAF�R.S', ' ii [i! t d DEPARTMENT OF ENVIRONMENTAL ILt ,TrC"IQ03 N TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: `5-3 U ,2 jo -L , _� a m t,nO'i M ti 1 I-T Owner's Name:ff L,c/Va�C Owner's Address: 1� Date of Inspection: Vlf O Name of Inspector: (please print) Skjs, Company Name: Mailing Address: aU Q n i,c1 AT, Telephone Number; So%- !:)!1 n 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 5 010 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �� - _ ,��--- Date: 1r,�/d� 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 r Page 2 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IXISPOSAL}SYSTEM INSPECTION FORM' PART,A . CERTIFICATION (continued) Property Address: •z a i 161fl Lei Owner: jpeS L,&r,r,',S Date of Inspection: a I u Ine> 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. J)_Jj.: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 Migh 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)m exeplaced., obstruction is removed. distributiod box is leveled or.replaced. ND explain: _j2A 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: I� j Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS r( SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3'3 i ,jija. t n Owner: eSL ^r s e�s 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 th system is not functioninIV a manner which will protect public health,safety and the environment: no Cesspool or privy is within 50 feet of a surface water ria 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. fta 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. 1oThe 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's*. 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. i f =d Page 4 of l l ,j OFFICIAL,INSPECTION FORM—NOT-TOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE D.i$POSAIY-SYSTEM•INSPECTION FORM •PARZ'-,A. . CERTIFICATION(continued) Property Address: ';_I U_ ,)j lc4 Owner: Date of Inspection: a., Cg� 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 .L 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 listribution 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'/a 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 i'00 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 c0form bacteria and volatile organic.componads 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 S ppm,provided that no other:.failure criteria are triggered.A copy of the analysis must•be 0ttached to this form.] . _(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 iqust serves 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 _Q_ Fj the system is within 400 feet of a surface drinking water supply ,o 1 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—I WPA)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. I. Page 5 of l I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 333 1 3j+,1, c► L n �rlr�4a(1�i r`n, cact Owner: Date of Inspection: 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 bin 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? j 4 Was the site inspected for signs of break out? x 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 m intenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no — Existing information.For-example,a-planat 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 CNN 15.302(3)(b)] Page 6 of l l OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ( SUBSURFACE SEWAGE;DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _3.3 U L n mu raji-®nS^Cn I'(J S TYh y Owner: D 6c"Lcil l r i 0 CS Date.of Inspection: ! o� FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-A Number of bedrooms(actual):_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 9� _ Does residence have a garbage grinder(yes or no):PO Is laundry on a separate sewage system(yes or no): nO[if yes separate inspection required) Laundry system inspected(yes or no):YC.S Seasonal use:(yes or no): Water meter readings,if available(1' 2 years usage(gpd)): q� Sump pump(yes or no): Last date of occupancy:L. e.)fi COMMERCIAL/INDUSTRIAL Type of establishment:- 00 Design.flow(based on 310 CNv R 15.203): __Rd 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:xo rn� p;,,j,,�, t—�a�ns�t>�� P�rnP•eel 5�'nC C I�t.4� o���17 Was system pumped as part of the inspection(yes or 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: Were sewage odors detected when arriving at the site(yes or no): Page 7 of I t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3-% j ),t jQ Ln ..tha+���n mar ci Owner: rj25LQu C%f'ftr5 Date of Inspection: a.l 11I BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of construction:_cast iron _g,40 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joint, venting, evidence of leakage, etc.): SEPTIC TANK: _(locate on site plan) Depth below grade: 2!!3 � Material of construction:A_concrete metal_fiberglass�)olyethylene _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: 1600 In n Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: R a Scum thickness: 1) Distance from top of scum to top of outlet tee or baffle: n p . Distance from bottom of scum to bottom of outlet tee or baffle:_r How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP;Oklocate 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.): Page 8 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3-1 U 1'n 10 (�n jpc�r o►'11;m►llgTr1:; Owner: o AS La cs r,.P c5 Date of Inspection: 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/day Alarm-present(yes or no): is 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:_ 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.): PUMP CHAMBER: (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.): f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �C PART C SYSTEM INFORMATION(continued) Property Address: L 3 U,'d 1 a La tY1r3I'Sfic�ClS p t q!-!, �YTra Owner• 1.dj - — Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type ICCQ leaching pits,number: leaching chambers,number:— - leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 't , + i i �1 i 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.): I 0 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 J i o L r, Owner- 'Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Lo ate all wells within 100 feet.Locate where public water supply enters the building. r 30 � Ns-- 4-7 i f . i Page 11 of 11 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �.(. PART C SYSTEM INFORMATION(continued) Property Address: 33 U-nip, L T! Owner: C,,gc t rj)( Pj Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: �4 Obtained from system design plafis on record-If checked,date of design plan reviewed: Observed site(abutting property(observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 28-M0-06 10:44AM FROM-ANGPROD +15088807232 T-310 P-01/04 F-821 44 Commercial Street Raynham, MA 02767 Tel: (508) 880-0233 Fax: (508) 880-7232 March 28, 2006 Barnstable Board of Health 200 Main Street Hyannis,MA 02601 Attention: Board of Health Agent Reference: Home FAST Treatment Serial Number: 26619 Attached please find a copy of the Product Registration Report for the FAST Treatment System for work performed on 03/24/2006 at the home of Jonathan Blake located at 36 Barberry Lane,Marston Mills,MA. Also, attached is a copy of the fully executed Inspection&Effluent Testing Agreement. If you have any questions or require additional information please do not hesitate to call. Sincerely, Donna L. Callahan Enclosures I 28-MAR-06 10:44AM FROM-JRENGPROD +15088807232 T-310 P.02/04 F-821 " ' U - MICROBICS ' fNC0RP0RATEO 8450 Cole Parkway m Shawnee, KS 66227 m Phone 913-422-0707 m Fax; 912-422-0808 e-mail: onslteiMbi microbl com 10 www.biomlcrobics_com w 800-753-FAST(3278) PRODUCT REGISTRATION REPORT Product Registration Report must be completed and returned to Bio-Microbics, Inc. in order to effect warranty. Date of Start-U - -0� Date Shipped to End User 12/12/05 Serial#26619 OWNER NAME Jonathan Blake ADDRESS 36 Barberry Lane CITY/STATE2IP Marston Mills,MA 02648 PHONEIFAX BIO-MICROBICS DISTRIBUTOR NAME Wastewater Treatment Services,Inc. ADDRESS 44 Commercial Street CITY/STATEMP Raynham, MA 02767 PHONE/FAX 508-880-0233 FAX; 508-880-7232 INSTALLER NAME Bevilac ua Construction ADDRESS P.O.Box 628 CITY/STATE/ZIP Forestdale,MA 02649 PHONE/FAX 509-833-4899 CONSULTING ENGINEER if applicable) NAME Down Cape En ' eerie ADDRESS 939 Main Street CITY/STATE2IP Yarmouth,MA 02675 PHONEIFAX 508-362-4541 Good Bad NA Good Bad NA ELECTRICAL PANEL(S) TREATMENT UNITS) Visual Alarm Operating 0 ❑ Air vent clear (�/ ❑ Audio Alarm Operating Septic tank level ❑ BLOWER(S) Septic tank meets min. size ❑ Wired for correct voltage 0 Septic tank filled to ❑ operating level Inlet/outlet piped correctly ❑ Air Lift Operation ❑ Filter element installed M ❑ Recirculation tube in place ❑ Blower hood secure ❑ Fasteners tight M__ ❑ Blower works correctly ❑/ ❑ WATER-TIGHT JOINTS Blower located within 100'of Treatment unit to septic tank ❑ treatment unit Air line clear m. ❑ Entrance tube to insert cover ❑ ❑ Air inlet screen clear ❑ Insert to insert cover all ❑ Blower hood vents clear ❑ Discharge line connection IJ 0 iL Factory Authorized Personnel: Title: Firm: Wastewater Treatment SeMces. Inc. Date. 28-MAR-06 10:44AM FROM-JRENGPROD +15088807232 T-310 P.03/04 F-821 `�YadGeu�al :Jieatirreict �Jc��yec�s, ,Dirt% 44 Commercial Street Please completem Raynham, MA all items arked• 02767 including three signatures. Mail signed original contract to: Wastewater Treatment Services,Inc. Tel: (508) 880-0233 44 Cgmmercial Street Raynham.MA 02767 Fax; (508)880-7232 INSPECTION AND EFFLUENT TESTING AGREEMENT Agreement entered into by and between Wastewater Treatment Services,Inc. (herein called WTS)and the FASP System OWNER(herein called OWNER)for the inspection by WTS of certain equipment of OWNER which is described below. Upon acceptance of this agreement at WTS's office,WTS will render the following services only: Equipment will be inspected at least 4 times per year that this Agreement remains in effect,with the first inspections beginning 4- -D(a . These inspections will include: 1) Testing of the sludge depth in the septic tank. 1) Inspection,power testing and clean/replace intake filter of the air blower. 1) Inspection of the alarm system. 1) Inspect overall condition of FAST*System. 1) Notification to OWNER of any problems encountered. 1) Service other than routine maintenance will be billed at an hourly rate,plus travel and parts. WTS shall notify the local board of health and Department of Environmental Protection in writing within 24 hours of a system failure or alarm event including corrective measures that have been taken. OWNER will be billed standard WTS charges for any parts used in repairs or maintenance_ Any additional labor time will be billed to the OWNER at standard labor rates of S74.00 per hour. Emergency service between regular inspections will be provided at standard labor rates during normal business hours;at time and one-half after 5:00 PM and on Saturdays; and at double time on Sundays and holidays. Emergency service charges will include a minimum four(4)hours of labor, plus standard WTS charges for parts,plus mileage and travel charges. The annual rate includes routine maintenance, but does not include repairs required for damages caused by abuse,accident,theft,acts of third persons, forces of nature,or alterations made to the equipment. WTS shall not be responsible for failure to render the agreed services if caused by strikes,labor disputes,non-cooperation by OWNER,or other factors beyond the control of WTS. OWNER understands and agrees that WTS is not responsible for special,incidental or consequential damages, including loss of time, injury to person or property,or equipment failure. OWNER agrees that WTS may enter OWNER's property and have acceptable access to all areas deemed by WTS to be necessary or appropriate for WTS to perform its duties hereunder. 28-MAR-06 10:44AM FROM-JRENGPROD +15088807232 T-310 P.04/04 F-821 °JuiF 15 u4 uz: oua This is a two-year contract which will be billed annually. All payments are non-refundable. OWNER's failure to pay invoices promptly or to otherwise comply with this contract may result in suspension of service,cancellation of contract and/or nullification of warranties,at the election of WTS. This agreement is not assignable without the consent of WTS and will remain in force until canceled b!,- either party through written notice. MANUFACC i'[IR1ER MOD O. .5ERIAL NO. LOCATION ANNUAL RATF Bio-Microbics MicroF T o7&(,17— Marstons Mill,,MA $420 i 0 EQUIPMENT OWNER Wastewater Treatment Services.Inc. *Signed by OWNER: Jonathan Blake Signed: 'Address: 36 Barberry Lane 44 Commercial Street " Raynham,'-VIA 02767 Tele: (508) 880-0233 *City: State: Zip: Fax:(508) 880-7232 Marston Mills MA 02648 *Telephone 50$-889-8154 Effective Date ofAi�reemenT_._ *Daytime Telephone OWNER understands that(1)ANNUAL RATE payment is for one year only of this two-year agreemew and is non-refundable;and(2)Current DEP Regulations require OWNER to maintain a service agreement for the life of the FAST* stem. Y VE READ AND UNDERSTAND THE FOREGOING. *Signed by OWNER: Influent&Effluent Te in - er local Board of Health Influent&Effluent samp ken monthly for the first 6 months theft quarterly thereafter and delivered io a qualified testing lab for evaluation. Results sent to State and local Agcncie5 as well as the OWNER. OWNER is responsible for providing acceptable access to effluent to enable a 8rab sample to 1v Tal(eTl for laboratory-testing performed. - PERMIT: *(PLEASE CHECK ONE) ( )GENERAL ( )REMEDIAL (X )PROVISION Al. *SPECIAL CONDITIONS PER LOCAL BOARD OF HEALTH(Y)or(N)if YF.S_please attach copy of permit (X )CBODS,TSS,pH,Nitrate,Nitrite,TKN,Alkalinity,BOD, Ammonia ( Other: *Cost for testing: $405.00/Visit Operator assigned: William Everett Telephone: 508 400-3868 *Engineer: [Do Cape 1✓ngmeering *Approval for Effluent'T'cstin ` H meo is Signature TOWN OF BARNSTABLE LOCATION aV6�14 49,e: SEWAGE # �02� VILLAGE oC?��P /y.�/S ASSESSOR'S MAP & LOT0g3-006-013 INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 14 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ► )( LAV\e- 3-6 Ir V ,No.... - .`�- '� FEs.....`4,?......''. THE COMMONWEALTH OF MASSACHUSETTS u BOAR® OF HEALTH Y �\ -Qw1�► OF...... ..................... Appliration for Disposal Works Tonstrnrfiun Frrmit p icatio is hereby made for a Permit to Construct (°/) or Repair ( ) an Individual Sewage Disposal at: .l n� LA�I� /�� '' -... ..... ...................................... .---•----------------........----•-• Location-Address or Lot No. -------- ----- .............................. ------------•--_-----.--. --:---------------------------- W Owner Address Installer Address UType of Building Size Lot...-�..../.. p ._..Sq. feet ►. Dwelling—No. of Bedrooms..................3......................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons..........--.....---.....--- Showers ( ) — Cafeteria ( ) P.' Other fixtures ------------------------------------------------•.d -•-•..-- -------•--------------- W Design Flow......................5.<..............gallons per person per day. Total daily flow........................ ....3510.....gallons. WSeptic Tank—Liquid capacity 1. gallons Length-------_------- Width................ Diameter...-..--.-----_ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...........I-------- Diameter...........`®... Depth below inlet........&........ Total leaching area.... 7...sq. ft. Z Other Distribution box Dosing tank ( ) -jA�w. {-I4 f Percolation Test Results Performed by.....- . .............A....4A. fb1............... Date. ................................... aTest Pit No. I-----73-!......minutes per inch Depth of Test Pit..... 1.....---.. Depth to ground water------------------- 44 Test Pit No. 2......1.....minutes per inch Depth of Test Pit....]_. ---------- Depth to ground wa ---•---•-------------------------- --------------------------------------------•-•-•......•--•---•... TDP0 Description of Soil............. ----•-•.- �' Cz"-:•=l•• ' ® S EPHf{�F x iLl_ ....................................................------------ - .-----AYH..---•- V(sl --------------------------------------------- -- --------------•-------.................--------------------------------••--.........-•--•--- ...-••.WILSON Nature of Repairs or Alterations—Answer when applicable.---.......................................................... . 6 N�o:30416 I --------•-------------------•-------------------•-----........-•----•---------------._.............---•---•--•-•. Agreement: Grric. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in or with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h s been issued by the board of health. J1-2 A® Signed ................... 1- Dare Application Approved By ... . --... ........................... �- `���� Application Disapproved for the following reasons: .... ....................... . ---- ------- -- .....------------------..... --- ------------------------ ----------------------------------------------- ------------------------------------------------------- Dace Permit No. ------ ---� "- �.�"�� .................... Issued -- -- - -- --------.................--- ---.........-- Date o.--• ••"/2�. Fps..... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ......... O..W.t4.................OF...... + t........................z ................................... Appliration for Dhiposal Works Tonstrnrt-inn ratnit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at: � q ............... .-----.•..... ��'1. ....... A41�'- '����( . Location-Address or Lot No. .�rti arm-�� w�?.vl��Il. _,�f.E.lrl!.� 7:..�CJlr_.`s.............................. .. L'2 .... ..-....... _............................ .......... ._......__.. _ .r..........................._ Owner Address a -•••................!Y% ....°°7------ c !ls �4'+..... .....--•--•-•----•-•--,.... ......................•-•--•--.....--•----------------•-- ,• U Installer Address Type of Building Size Lot.___...._.t...:�.__........Sq. feet ...............____..___.____..____._Expansion Attic ( ) Garbage Grinder ( ) V Dwelling—No. of Bedrooms... Other—Type of Building No. of persons____________________________ Showers — Cafeteria Q'I Other fixtures, W Design Flow______________________`:].______._._____gallons per person per day. Total daily flow............................. ®.....gallons. 9 Septic Tank—Liquid capacity_11_S gallons Length................ Width................ Diameter________________ Depth................V W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No............________ Diameter...........t.0___ Depth below inlet_____.__(_........ Total leaching area..... S-7._.sq. ft. Z Other Distribution box ( t.ey Dosing tank ( ) 13AK i t at"� 4- 14+j 0 -- 1 V"L77-07 NI .� .�/tCyc't -_ :'�38 0-4Percolation Test Results Performed by................................... ____________________ _________o____ �.-------------- Date__��._ ................. IL ,,-a Test Pit No. 1................mmutes per inch Depth of Test Pit_._..____q_.._..__. Depth to ground water__ (r4 Test Pit No. 2........ `_____minutes per inch Depth of Test Pit.....13......... Depth to ground wat P4 -•.--------------------------•-----•_-_•••------•._...__......-_... _ t--------------------- Descri tionofSoil_______________F � _-'"--• ? ..'... - '`?--._ _'~a: ...---•-••---•----•--- STEPHEN x P A pia- _... II•------------ - -� .............. . m d`131 - ---------------------------•-----------_...----......--•--.•....-------------••••••-----............---•••• -X-........................................... . ..... ,x -•------------------------ ............................................................................................................................................. .... ..�-N U Nature of Repairs or Alterations—Answer when applicable---------------------- ...............................-............................................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in cordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by the board of health. Signed ........ - - - . --------- Dare Application Approved BY ---------- ;'� , [✓ - P `... /...-.-3-- / 1 Dace Application Disapproved for the following reasons: .................... .----------------------------------------------- -- ------. ........--........------....------------ -------------------------------------------------------------------------------------- -------- ----------------------------------------------------------------- --------------------- ------------ ---------------------------------------- Du PermitNo. ........P..r.:...�.`a ---------------------------- Issued ......................------ --- -- -------........------. Dace THE COMMONWEALTH OF MASSACHUSETTS BOAR HEALTH lr(1 ------------------- OF ....... �V '----------------- Ceztiftxtt#e of C ontyliattre THIS IS TO CERTIFY, That the Individual Se,,wit Disposal $y Y nstructed ( "` ) or Repaired ( � ) b - _ C�'"! --------- Ins[aller at .'"�'� .. .----flA*6141--- - ----------000-'�g± � -tea...-- ` �' - � ------------------- has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No, 1-.. •..Z.1..--------- dated ....................................... ......... THE ISSUANCE OF THIS CERTIFICATE.SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------------------------------------------------------------------------- Inspector .----......-------........--.....................................----.------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0wt.4:............... F._..... O sPt•t� t..T t:�:......-•................................ DisVosal nrku (tans ion amit Permission is hereby granted.......... I� .•-•'- .ems.... C'r to Construct (t�or Repair ( ) a ' Individual Sewage Disposal�, ystem atNo ....... ':_. .__... ..._.._... Street as shown on the application for Disposal Works Construction Permit o. !�.92,, Da .....................- ----- Board of Health DATE............... _ r�. FORM 1255 HOBBS IN WARREN. INC., PUBLISHERS a S/ G D4•/(�/ ,cep� �, ' //O X 3 _ 3� 6•P� i 7 - �/5 1 170 �9 s. x77 TD7x1L I�ESi�,/ - 5zy a.P. D. Lor"-3 j Tb7A4L L FLoW/ = 330 ,1.Cd'- �'.^.�.` _7•_•.•�F fit.' .�._ '�-• ' •'' ... i �' � I STEPHENWILSON ALLYN 140.30216 ram. .6-7L:'V/- �W---. G.. (>uN�/i✓� -3.�.hF, T< w l7x!/n/ /z'�. , BOX //V✓. GAL, , l-L-4 /�'/� ✓lam/J .t /jax-11110 -b `/�n� ��+�j �-•- G" _ .. 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SUM P EL. 74- 43 �- • �}-" —� 1� "I "`�+ F/�c!/5'H• GSA D E ` v T/NG 15 000 6AL. SEPT/C TANfC ZS` �" MAX. ,9P,PX0Y5,b BY -T/TLE /=/VC- /1VsP,6:-C-'/O/V, �• 4,3' So/�- s ABsoRPT/GIN 5Y�TEM l MIN. co NC- COEE , 3G IvIf1X- RISER 2 ' J? coF �f 0 s-/ 0 V, SEWAGE SySTE/VI p�S/�a/L/ CAGCUGAT/ONSL, 74. 0 307 rOA4 OF 7ES r f'/7 l.._ a /, DES/G�/ Df1/G Y FL 4LV _l'/z �2)5G'JG_ CI ?N'B iE'S /g WASH E,D E=i 3.30 GPd G �N�WAL - N47'�S Lt/,gSI�E,a .5TOA45 — r--j C01V5- eZ1CT10,A1 A/V.L> M,4TESA'1.4G5 S'IIAGL 7-0 Cr STGh/� .D�PTN TL FI V, .4�/d ,6,41,?Al,5A6 f- BOARD DF h'EA-LT/-1 REGULA7-/ON5. 3 3 o 6,00 T/ - OC. N� SfiA tL BE f � of DUST ANa / I p3. L/sE 7-WO 5Do GAL Z �OG/BL E kf14S1-1.Cb s'TO -- ,9,/3SD�PT/D/� D/'YCOV&gY o� 5'0/1-S /A1f^ONsiSTC-ivT L4//Ty 7�VE %�s7- P/Ts S/�.9L L SE f'EPDF'T�1� TO 77/6 1�ES/G,NER. S/LSE AREA G O, t 30 To�-AZ Ah�EA = 7/ P&L�,1� kV/Th' SA/V Z) 5 CAA h,- 1OV, , G. 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