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Home My WebLink About0765 WAKEBY ROAD - Health 765 Wakeby Road Marstons Mills A= 012 —007 - 002 1 � TOWN OF BARNSTABLE v LOr-SnON �� SEWAGE # VILLAGE //�Q p��4 ��/�S' ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.�C SEPTIC TANK CAPACITY /640G Q2/l,/9 LEACHING FACILITYAtype)�" ( (size) NO. OF BEDROOMS � QVATEPUBLIC WATER BUILDER O DATE PERMIT ISSUED:T/�� DATE COMPLIANCE ISSUED: .� . VARIANCE GRANTED: Yes b �y ' o 7y , o P� EI?c 28 2009 11 : 40AM PRTRICK OCONNELL 5084281613 p. 2 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 765 Wakeby Road Property Address Scott Berkey Owner Owner's Name information is Marstons Mills MA 02648 December28, 2D09 required for — every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important: A. General Information When filling out p � faints on the q computer,use 1. inspector: only the tab key 10 move your Patrick M. O'Connell _ cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. _ Company Name � 1 t39 Cammelmet i Road Comparry Address Marston Mills MA 02648 ^ City/Town State Zip Code 508-428-1779 SI 12855 _ Telephone Number License Number B. Certification a 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 situ' sewage disposal systems. I am a DEP approved system inspector pursuant to`Suction 16.340 of Title 5 (310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails - ❑ Needs'Further Evaluation by the cal Approving Authority. to December 28,2009 In ctor's Signature Date T The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of ufte at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I I M271 8erkey.doc•080 Title 5 Wdal Inspection Form:pb-llfs Sewage Dispo 15 Ys lem•page 1 of 15 j I ` r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M .765.Wa keby Road Property Address Scott Berke Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time leaching system shows no evidence of surcharge or hydraulic failure. 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 j 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: j ,i i i i i ❑ 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): i { ❑ broken pipe(s) are replaced ❑ obstruction is removed 09-271%20Berkeyili•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 j Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every State Zip Code Date of Inspection page. City/Town B. Certification (cont.) B) System Conditionally Passes.(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: i 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 i i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh j 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: ElThe 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. 09-271%2OBerkey[1].08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 765 Wakeby Road Property Address Scott Berke Owner Owners Name information is Marstons Mills MA 02648 December 28, 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be i attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or ❑ ® clogged SAS or cesspool El ® 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 4 ❑ ® than day flow Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 09-271%20Berkeyili•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 765 Wakeby Road Property Address Scott Berkey Owner Owner's Name information is MA 02648 December 28, 2009 required for every Marstons Mills page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection El El 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 r system considered a significant threat under Section E or failed under Section D shall upgrade the i system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. u i f I 09-271h20B o erkey[t]•06106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 , _C\ Commonwealth of Massachusetts AMR Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every State Zip Code', Date of Inspection page. City/Town C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information 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. i 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)] I i 'i `i Disposal 09-271°h208erkey(1]•08106 Title 5 Official Inspection Form:Subsurface Sewage p osal System•Page 6 of 15 s Commonwealth of Massachusetts Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 01 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is MA 02648 December 28, 2009 required for every Marstons Mills page. CitylTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No N/A Pool Water meter readings, if available (last 2 years usage(gpd)): Sump pump? El ® No Unknown Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) i Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ElYes ❑ No Industrial waste holding tank present? El Yes ❑ No j Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No i Water meter readings, if available: Last date of occupancy/use: Date Other(describe): '� 09-271%20Berkey[1]•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped in 2006 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and ❑ maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I i i I Approximate age of all components, date installed (if known)and source of information: I New leaching system installed in 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Ii ,4 09-271%20Berkey[l]-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every State Zip Code Date of Inspection page. Cityfrown D. System Information (cont.) Building Sewer(locate on site plan): 3' Depth below grade: 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.): Septic Tank(locate on site plan): 3' Depth below grade: 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 ---------------------------------------- i --------------------------------------------------------------------------------- 8.5' long x 5.2'wide- 1000 gal. Dimensions: r 3"t Sludge depth: t 27" i Distance from top of sludge to bottom of outlet tee or baffle Trace Scum thickness '1 6, .1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom"of outlet tee or baffle 13" How were dimensions determined? Measured !i Page 9 of 15 09-271%20Berkey[t]•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is not in need of pumping at this time, tees are intact and clear. Liquid level was found at bottom of outlet invert. 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.): i I I 1 Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: s E Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): ;j 09-271%20Berkey[t)•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 765 Wakeby Road - Property Address Scott Berkey Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every page. City/Town State Zip Code Date of Inspection i D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): 0„ Depth of liquid level above outlet invert 1 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.): No solids or high stains . Pump Chamber(locate on site plan): ' Pumps in working order: El Yes El No a Alarms in working order: El Yes ❑ No 09-271%20Berkey[11.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is required for every Marstons Mills MA 02648 December 28, 2009 page. City/Town State . Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: Four 44 galleys. ® leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: j ❑ innovative/alternative system I Type/name of technology: i .i Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): f Area of SAS was probed with no signs of saturation. i I ) :I e 12 of 15 09-271%20Berkey(1]•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Peg I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 765 Wakeb r Road Property Address Scott Berke Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every State Zip Code Date of Inspection page. CityTrown D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: i Dimensions I Depth of solids - { Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, i etc.): t { ] 'I 09-271%20Berkey]1]•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is Marstons Mills MA 02648 December 28, 2009 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) 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. I i i i i I I I i i zg:I Ji ? ; , :i ii 09-271%20Berkeyil1•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 :I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 765 Wakeby Road Property Address Scott Berke Owner Owner's Name information is MA 02648 December 28, 2009 required for every Marstons Mills page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 30+ Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: i ❑ 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: USGS topo map and town GIS I i ` You must describe how you established the high,ground water elevation: 1 Town groundwater contour map shows water below el. 50 and topo map shows property above el. 80. i I I i [ � I ,i Disposal System Page 15 of 15 09-271%20Berkey[1j•08106 Title 5 Official Inspection Form:Subsurface Sewage • y ��"esOF �9 1 c Deck 91 74 9g 81 i ..I { a COj/1-?ONT°rE_kLTHOF ASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONTIMENT_AL AFF_,URS. 15 DEP.ARTMr-?iNT-OF.E+ N-VIRO:-NIVIENTAL PROTECTION TzTLE 5 OFFICLk INSPEiCTIOT'+ FOR NI—NOT FOR Y:bL NTARY ASSESSMENTS 5:1:1BSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A XCE RTIFI CAT ON Property Address: Owner's Name: - Owner's Address: Date of inspection: f / Name of:nspec#or ;pas'e pr int; �'t� r► -Company Name:': Mailin7.A.ddress:. Telephone Number:. CERTIFICATION ST:ATEIMEN i.ce-airy that I'.have personally inspected the sewage disposal system at this address and that the information reported below is tree, 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 Se-etion 15.340 of Title 5(310 CMR 15:000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving-Authorivy 3 Inspector's Signature: Date: F0(3t� The system inspector shall submit a copy ofthis inspection report to the Approving Authority(Board of Health or DEP)within 30 days of cor_tpleting 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 ofttce: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 E/15l2000 page I Page 2 of I l OFFICIAL, INSPECTION FORM-itiOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWA.GE'DISPOSAL,"SYSTENI INSPECTION FORM::. PART A CE R 1 IFICAT O �I I c o�t"lnuzd Z Property Address: �r Owner:. } Date of Inspection: Inspection Summary: Cheep- A,B,C;D or E/ALWAYS complete..all of Section D A. System Passes: y� I4have not found any information which'indicares that anv o"the failure criteria described in 3 I O CMRT 1 5.303 or in 3.10:CNIR 15.304 exist. Any failure criteria.not evaluated are indicated below.. Comments: B. System Conditionally Passes: One or more system components.as described,inthe"Conditional.Pass"section need to.be replaced or repaired.The system,upon completion of the replacement or repair; as approved bythe 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 an&over 2.0 years olds 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 tanlc.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 indicatina'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 un.even.distribution box.System will'pass inspection if(with approval of Board-of Health): broken pipes)are replaced obstruction is;removed distribution box is leveled or replaced ND explain: The system required pumping more than.4 times a.vear 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:. Page 3 of 11 OFFICIA.L, INSPE CTION FORM -NOT FOR.VOLUINTARYASSESSMENTS SUBSURFACE SENVAGE DISROS_,kL SYSTEMINSPECTIONFORIM PART:A CERTIFICATION(continued) Property Address: /COS '�� -r� Owner' Date"of'Inspecrion: C. Further.Evnluation is Required by t3he Board.of Health: Conditions exist which.recuire 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 pri,,w is within 50 feet of bordering vegetated wetland or a salt marsh 2.. "Sys:terri will fail unless thi¢Board of Health(and Public.Water Supplier, if any).determines that it e system is functioning in a inanner th:at.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 Ovate-supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 sys em'_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 coliforrn bacteria and volatile organic compounds indicates that the well is.free from polfution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided thatno other failure criteria are triggered. A copy ofthe analysis must be attached to this form. 3. Other: 3 Page ^-.. of I l OFFICIAL:INSPECTION bR-mI .NOT FOR VOLUNTARY ASSESSIMENTS . SUBSURFACE SEW AGE DISPOSAL S:YSTE M-INSPECTION FORM PART A. CERTIFICATION:(continued) Property.Address: t✓Q 3 'Owner "Date of Inspection: �, QOU(A D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the following for all inspections: Yes N :. 7,I Backup of sewage into facility or system component due to.overloaded or ciogeed SAS:or..cesspool Discharge.or ponding of effluent to the surface of the sround.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 f cesspool, Liquid depth in cesspool is less.than 6" below invert or available volume is Iess than,%day flow Required pumping more.than 4 times in.the last year NOTdue to clogged or obstructed pipe(s).Number of-times pumped (, Any portion of the.SAS,cesspool or privy is below high around water.el.evation. 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 cesspooI or privy is within 50 feet of'a.private.water supply well.., Any portion of:a cesspool or•privyis.less than 1,00 feet but greater.than,6:0 feet.ftom a private water: supply well.rvith.no acceptable—water qualityanalysa:.[This System passes if.tfie well water analysis, performed at:.a DEP certified laboratory, for colifor.m bacteria and:volat'ile organic' compou:nds 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 ppin,.provided that no;other failure criteria are triggered.A copy-of the analysi"s..must be attached to this form:..].. (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described:in 3 10 CivIR 15.503,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 1.5,000 5pd. 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 within400 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 lame system.considered a significant threat under Section E or failed under Section.D shall upgrade the system in accordance with 3,10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. i t ,I Page 5 of 1.1 . OFFICIAL I'_YSPECTIOI,I FORi`v1—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEA GE DISPOSAL SYSTEM INSPECTION FORM PART E CHECKLIST re Property Address: Owner: Date of Inspection:U,14 L /,� � � Check if the following have been done.You must indicate"yes" or"no'' as to each of the following: Yes. No r f— 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 NIA) _ Was the facility or dwelling inspected for signs of sewage back uo ? 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 e;baf_ies 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 examale, aplan at the Board of Health. _ Determined in the feld.(if any ofthe failure criteria related to Part C is at issue approximation of distance is unacceotable) [310 CISR 15.302(3)('o)I 5 Pave 6 of 11 OFFICIAL INSPECTION FORIM, —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA°RTC . SYSTEM-INF.ORMATION Property Address: Owner: Date.of Inspection: . LOW CONDITIONS RESIDENTIAL Number of bedrooms.(design); Number of bedrooms(actual).: —� DESIGN flow based on 3 10 CMI , 15.203.(forgexample: 11.0 apd.x T of bedrooms):. Numbei of current residents:. Does residence have a garbage grinder(yes or no): A/0 Is laundry on.a separate sewage system (_y�e or no):/ yes separate inspection required] Laundry system inspected(yet.or no): Seasonal use: (yes or no): J Water meter readin-s, *fa ilable(last 2 years usage.(gpd)): 1 i t Sump.pump_(Yes or no). Last date of occupancy: d.� l � ✓ jQ�� C� , COM.MERCIAL/INDUSTRIALo Type of establishment: Design flow(based on 310 CMR I5.203): gpd Basis of-design flow (seats/persons/sgfc,etc.): Grease trap present(yes or no);_ Indust_ial 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: ,! 2 Was system pumped as part of the inspection (yes or no). C If yes, volume pumped: gallons--.How was quantity pumped determined? Reason for pumping: T} E OF SYSTEM Septic tank, distribution box,soil absorption system _Single cesspool _O'verf?ow cesspool. Privy _Shared system (yes or no)(if yes, attach previous inspection records,.if any) _In.novative/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): A roximate age of all co pone ts, date installed if known)and so1jrce:of information:' s, 7 Were sewage odors:detected when arriving at tfie site (yes orno): C Paze 7 of l I OFFICIAL INSPF:CTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE"NAGE DISPOSAL SYSTEM INSPECTION FORM PART C 9Y,STEM.INFOR-M-ATION(continued) Property Address: j Ila, t,Q . Owner: Date bf Inspection: ?�p �, g,a Z60 BUILDING SEWER(locat?on site plan),,A/b Depth below.grade: .Materials Of construction:_cast iron 40 PVC_other(explain): Distance-from private water supply well or suction line: Comments(or, condition'of ioints, venting, evidence of leakage;etc.): SEPTIC TANK:Zlocate'on site plan) a Depth below grade: ,l Material of construction: concrete_metal_fiberglass_polyethylene _other(exp lain) If tank is metal list age:_ .Is age confLrned by a Certificate of Compliance(ves or no): _(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of s�udcre to bottom of outlet tee or baffle: Scum thickness: J/`. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee Qr baffle: 9d _ How were dimensions determined: Comments (on.pumping re commendations; i_ler and outlet tee or baffle condition, structural integrity, liquid levels al related to outlet invert, evi ce of leakage, etc:): . V GREASE TRAP�� n(locate o site plan) Depth below grade: Material of construction;_concrete_metal_fiberglass_ polvethylene_other (explain): Dimensions: _ Scum thickness: Distance from top of scum to top of outlet tee or battle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last.pLmping: Comments (on'pumping recommendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet.invert, evidennce of leakage,etc,.): 7 , Page 8 of I 'OFFICIAL..INSPECTION-FORM-NOT-F0R.` QLUNT�,-RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSP:ECTIO-'N1 FORNI PART C S.YSTEM:INFORNIATION-(continued); Property Address: 1% "4 Owner: ' Date of Inspection: ®1l CD TIGHT or. HOLDING TANK: {tank must be pumped at-time ofinspection)(loc.am 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):. Alarm level: Alarm in working.order(yes or no): Date of last pumping: Comments(condition of alarm and float.switches, etc.): DISTRIB.LiTION BOX: ;f present must be opened)(locate on site plan). ( Depth,of liquid level above outlet invert:7LI:ZG �"'� , Comments (note if box is.level.and distribution to outie s/equal, any evidence of solids carryover, any evidence of d age into o, out f box, 1 PUMP CHAMBER:. (Iocate 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.): Pase 9 of 11 OFFICIAL.INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE BISPOS:AL SYSTEM INSPECTION FORM PART:C SYSTEM INFORVIA:TION(continued) Property Address: Own e.:. '• Date of Inspection: JA '� � SOIL ABSORPTION SYSTEM (SAS):JZ0ocate on site plan, excavation not required) If SAS not located explain why: Type leaching pits,number:_ .1peching chambers,number: leaching.galleries, number: leaching trenches, number. Xarvh. leaching fields,number.:dimensicns: overflow cesspool,.number: innovative/alternative system- Time/name of technology: Comments (note condition ofsoil_. signs of hydraulic failure, level of ponding, damp soil, condition of vegetation; aAA,etc. : ° r CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and coniQuration: Depth=top of liquid ro inlet invert: Depth`of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication ofgroundwater inflow (yes or no): . Comments (note coil dition'of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate or site plan) Materials of constriction.: Dimensions: Depth bf solids: Comments-(note condition; o-soil; signs of hydraulic failure level of pondirg, condition of vegetation; etc.):. 9 Pane 10 of 11 OFFICZ�L INSPECTlON.FORiYl'".-NO'T FOR VOLUTYFARY ASSE SSMENT.S SUBSURFACE SE-WAGE DISPOSAL..SYS E�rI.? SPE.CTIOi`i FORM PART-C SYSTEM INFORMATION(continued} Property Address: ,j Owner Date of Inspection: SKETCH.OF SEWAGE DISPOSAL SYSTEM Provide asketch of the:sewaae 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 buildin1g. OM =... Ct of) Uf NJ Iwo c LAV'i. d- ru � O Page l I of I 1 OFFIC.LAL INSPECTION FORvI -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT I PART C S 'STEM INFORRMATION(continued) Property Address: Al Owner• Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground wafer 3b feet Please indicate(check) all methods used to determine the high gr6und 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 Iocal Board of Health-explain: Necked with.local excavators, installers- (.attach documentation,) 'ccessed USGS database-explain: You must describe how you established the high ground water elevation: Il Permit Number: ,may Date: Completed by: ;/f- HIGH GROUND-WATER LEVEL COMPUTATION Site Location: /r--e y' �'�Q' Lot No. Owner: 1_121,,71110 Mgr Address: Contractor: Address: �? i5�`r'Y STEP 1 Measure depth to water table s to nearest 1/10 ft. .............................................................................. ;Date.- month/day/year STEP 2 Using Waster=Level`Range Zone and Index Well Map locate site::and determine:. OA :Appropriate.index well............ ✓ .. 3 OWater level range zone ..................................................... STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to � Water level for index well ........................... Al 2 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),current depth to.water level for index well (STEP 3), -and-water-level zone (STEP 213) determine water-level adjustment .......................................................................................... ' STEP .5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to waterr� ` level at site(STEP 1) ...................... Figure 13.--Reproducible computation form. 15 is 4®0 I_. Oo7 �Z THE COMMONWEALTH OF MASSACHUSETTS /FEi&.............................. BOAR® OF HEALTH TOWN OF BARNSTABLE Applirativit for DinVniial Workii Tonitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (i�4 an Individual Sewage Disposal System at: 74; --�`! =4-`-�------�------ . ...................................................... �ze�s----fir csc..s , ---•• c ocatioc arc s .2pd'; ^� or Lot No. ------- --------------------•---- --------- -•---•------- ---------- Owner '� Address F11 Gf/a.rs`�Ztvc'�i ...! '7(� '? & ✓�I �1_ •--•--- 6 -- --/ ----.----- - >ILt.SC............... Instalter Address Type of Building Size Lot__ _________________________Sq. feet Dwelling— No. of Bedrooms_______________ __.___.__.____.__.._.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) A4 Other fixtures- _______________________________ _ _ w Design Flow_____________ __ - _________________gallons per person per day. Total daily flow...-.-._--_____� e_______._.___...gallons. WSeptic Tank—Liquid capacity/000....gallons Length---------------- Width-_---- --_-__.- Diameter---------------- Depth---------------- x Disposal Trench—No. --------/........ Width.....F----------- Total Length---:!!?9__�Pfotal leaching area___.................sq. ft. Seepage Pit No.......4 ......... Diameter---/.Q_`........ Depth below inlet____________________ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.-.---_______-_-- __ Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.__..._____--_--____ Depth to ground water........................ a -------------------------------------------------------------------------------------------•._............. ••••-• .. ----------------------•-• ••••-•_-----' 0 Description of Soil........................................................................................................................................................................ x w U Nature of Repairs or Alterations—Answer when applicable---------- ......w1-7rl....c- �„S ---------•.......................•--...---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance 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 Vs b en issue y t4e board of health. Signed .................... ...... ...... ........1.....�............. Dac Application,Approved By .............. -.. --c, ----------------------...... ..., .^...��.>......—....------------------ Dace Application Disapproved for the following reasons: ------------------ ----------------------- --------------------------------------------------------------------------- ......... . ................................. ...... ................ ... .................................... .................. ........................................ Dare PermitNo. .........?,_ -------X 7.6---------------------- Issued ------------------------------------------------................ Dare 7, o� - 76 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ApplirFatiuu for Dijapwi al Ourkw Tomitrurtion Pumit Application is hereby made for a Permit to Construct ( ) or Repair (p4- an Individual Sewage Disposal System at: ....� G�a�s-nL�6`......--� `M °s '`` -c.�s = Location---Addccss or ......................f1C �ctc_ <,...........................7� ?..........................................y / ; t ........... �--� Owner a /S/�✓!�i Address CGS / U �Gl S --Installer Address UType of Building Size Lot............................Sq. feet ►, Dwelling—No. of Bedrooms---------------- ----------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—' Type of Building ____________________________ No. of persons-------- .------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _ W Design Flow...............:`;..................gallons per person per day. Total daily flow................... .................gallons. W Septic Tank—Liquid capacitylcou----gallons Length---------------- Width-------I--------- Diameter---------------- Depth................ x Disposal Trench—No. ....._..�__._._.__ Width..... '............ Total Length--. ..?`_ ' otal leaching area....................sq. ft. 3 Seepage Pit No....____f.......----- Diameter..:_ 0.. ........ Depth below inlet____________________ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---------------------------------------------------- ••---•----•--•------- Date........-------------•-•--........... a Test Pit No. 1................minutes per inch Depth of Test Pit.______-_______-.-__ Depth to ground water........................ f� Test Pit No. 2................minutes per inch .Depth of Test Pit-------------------- Depth to ground water........................ �+ ---------------------------------------------------------------------------------------------••--••......................................................... ODescription of Soil.....................................-------------------------------------•----------------------------...._._..-----------------------------------------•-------_----. U ...............................•---•-...._.5'•---•^_______-----•---•--_•___________...._.._____......._-•-•-----.....-.----.....--•-----•---....__-•----^•---...-•-•--________._..._______•-•••--••-•- W U Nature of Repairs or Alterations--Answer when applicable,4-1)z._........! ___-_ . ....... .. .....................................�--'........ f—�-ram` -/!N ----ES L ........................... .-- ................. Agreement: I , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance 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 ben issue y t.e bo('a�rd of health. / /gam. Signed;..... ----JG ✓ ✓(-..------;- ----- f f ( / 1�/lam Application.Approved By ............... 1 - '.. .5.- .. Date Application Disapproved for the foil w ng reasons: ....._................................. ..............._................................................ .............1:...:. ............. - ..... g Dace PermitNo. ---------f..---- z L - Issued"``------------------------------------------------------------------ ^v,, Date THE COMMONWEALTH OF MASSACHUSETTS 01Z —0 2 BOARD OF HEALTH TOWN OF BARNSTABLE ' Certifirate of Graptiance THIS IS TO CERTIFY�t the Individual Sewage Disposal System constructed ( ) or Repaired ( Off) ��`"Gw�l Gc jv.sTiLv c� (-U J by ... ............. ..._ ..-----------.-..----- --------...---------------------------------------------------------------------------------------------------- atms�.air ..... ............ .... - G !'!,Z, 1y1' r-� 7 t 15------------....-------..--------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... ,5`-.-_-... _7.(--___- dated ------------------------- -_- .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISF TORY DATE....... .......... �.-l�` ---- ..?��.---------- Inspecto r� ....-...... THE COMMONWEALTH OF MASSACHUSETTS V/ 7, BOARD OF HEALTH TOWN OF BARNSTABLE No...... Disposal Worhn Towi#rudiatt '"amit Permission is hereby granted----------------- G,ZZ "7 CL411 r sue.`-`-.r-r c'ti to Construct ( ) or Repair (>ey an Individual Sewage Disposal System .. lC� ` �at No............................................--7--6 ................................................ ........................ . .....5.----------..............--- Street /5- 7/ as shown on the application for Disposal Works Construction Permit No__ _ _, _ a___ Dated------:_�_-..,(�_._^:...�/a..�........ 011 f Health DATE _ < 1--------------------------- V FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS E0 AT ;C SENA, G PEA M17 NO , HST �A s � H'S Id & ICE A ADDRESS NAV DATE PkRMIT ISSUED � vZLlF'& ELATE COMPLIANCE ISSUED .�_ � 'SACK 7 ?g � � FRic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL-r Lj Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal C4. ..... ..... 01111%............................ . . . ................................... jfocation;A IV Owner Id$kesr ...... Installer Address 14 Type of Building Size 04 Other—Type of Building 'j1d4.-Vjd�AX-. No. c6 persons'--,� ................ Showers ( ) -- Cafeteria ( ) w Other fixtures ----.--_'-.-_--_------'-.-------.-_.._._-'--------'_-------___. � Design Flow..,/,5to..........................gallons per person daily flow....... 04 Scy6cTuok--l.kluidcupucty./40x*.tuloos 1.eogtb-AnrVYidtb-��... Diameter.---'-' Ueytb-.-I��'0� DisposalTreuch--I�u-..-----' l�iidh-------..-. TotalTotalleaching area.-------'--ug. f t. � Seepage Pit No....../........... Diaoetec.--��&..... Depth below Total urcu-_------ml. f t. � 08zcr Distribution box ( ) Dosine tank ~~ Percolation Test ResultsPerformedby ... .- -.-----.--. Dute--Z.,!� .. �� Test Pit No. l-.��-miuutea per inch Y Depth of Test Pit---------' Depth to groundwater-�T 3w$ Pit No. 2................minutes per inch Depth of Test Pit.................... Depth toground wuter-.------.-.. � Q Description � o� ��~� _---_.--.-------'. �-zc-� --. ---��*m0��----. �� .��~........................... � --.------------_-.--'---'---------__--_--_-----.._-_-----'--_---_''.'_-----'----.. � U Nature of Repairs or Alterations Answer when applicable----------------_---.---.--..-_-------- | ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with i i ofIlTIMj 5uf the State Sanitary CodeTbe undftned further agrees not to place the system in operation until a Certificate of Compliance: ee is I by the boar 'o . S ....................... --' -_-----'--- Aooicu600 Approved Dy'-.--' -/~"�'. --'------------'--- --~�' ./��'��--- Date Application Disapproved for the following reasons:................................................................................................................ � ______ _________ Date Permit No Date No... ............ --J FEs.....:. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -f Appliration for BiipoiFal Workii Tonstrur#'ton rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --� ..................................................... Location.Address °{ or Lot No. ...........' ••... —ram......• .........s ....... / .. . '...................... .�==�-- = '� �............. } .....x r t' Owner f , Address a .........-�....................._... .................................. .......................................................................... Installer Address d Type of Building Size ......Sq. feet U Dwelling—No. of Bedrooms......... ...............................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ....::...................... No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------------------------- - W Design Flow........ ________________________gallons per person per day. Total daily flow...................._..._....................gallons. WSeptic Tank—Liquid capacity._!......:gallons Length_... _.._L Width.............:.. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........:........... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - . Percolation Test Results Performed by.................ef....................................':................... Date......................... ._ Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water................. .. L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ o4 •----_-•---••------------•.= .....................................................................•-••--......••-•.............••- ---•-..........................._�,......�...-----...,-----._...................... ................................... O Description of Soil -•----------- ------ ' ": " '� ._........ --- - -•---- .............�•. --•---•••.. !---........... --- x / / d. ✓ b. ..------.--•U 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 Compliance has,been issuefl by the board of healtli: 4 Signed.................. `� -......( ...............•----•-•-•• Date Application Approved By•••--••--=_'_=I^ 'f -"`— - ?-�--t e-1;Z . ..... Date Application Disapproved for the following reasons:................................................................. ......................................... -•--------•----------•------•----....----•--•----.......-•--•............................................•------•-------------•--...--•---••----•.........-•----•-•-•--• .--•--....---------•--•••...... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF r. . , f (9rdif irate of Tompliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by•••.....� . - 1 --... � .,x ............ ..•-.....---••--•--•---••- ••--•-.....••-•••-••-•..........•-•-•--••••..............••---•--------•••-••--................ ....i Installer u t c� V"S—t IC G�✓l at •--•... . ----- -----• -----•----•-.. ........... .-•----- has been installed in accordance With the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......` La...-... dated_...____ ..L`T.�(.�` .. ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIO AT SFACTORY. _ DATE................................. � .-----------•..••••-• Inspector............ .......................................••-•••••--............-- THE COMMONWEALTH OF MASSACHUSETTS \ BOARD OF HEALTH ,, t n ( r ' OF. .................. .� . '. No.... `. .......... FEE........................ Dispant Work.5 amit ;�� ;; Permission is hereby granted...---= -- -------------------------•----.---•---•-----•---- .............................................................. to Construe !) or Repair (�) an�Ind�ivid lwage Disposal System atNo. ..............•---•••----•-••..•••••------------•--•--•......•---••--••----•••- .............................................. Street V( I -'�p 1 o as shown on the application for Disposal Works Construction Permit No..................... Dated.... /__.... �....................... ! f Health � -•--••-•------....--•----•---• o ea -----••---......... Board _ DATE.-`` �' = .:..------1 ....................................... FORM 1255 A. M. SULKIN, INC., BOSTON c C 'WC Fi2o No. 366 �, !{b4 f .G. NTA6ars .�ONAI kj mk r tw-M / �Ycqp cc.f a S �osr '13, 7G 2. SA d T �Y AL All t \ r7 L o T tA I 00 — Po.✓c c' -. 7Z `/ o' � K I7 1 �AiI LEGEND A«wI- � + -� T°'"ea.c��b EXISTING SPOT ELEVATION Ox0 'r°i" �' CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 - - .07- 2 V-IAkE �( s FINISHED SPOT ELEVATION FINI.SHED CONTOUR 0 NIAr? STonlS ` .�-� r[L, {. IN APPROVED BOARD OF HEALTH . DATE AGENT SCALE] „s�_o - DATE"1.2. L—D-RE—OGE ENGINEERING CO. !N �^ - -- CLIENTZ�lh,141 OiN I CERTIFY THAT THE •PROPOSED EGISTERE REGISTERED J08 N0. .F S�.,/09 BUILDING SHOWN; ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING lAWS1 E GINEER URVEY DR.HY� OF 8ARN5TA8L MAS 712 MAIN STREET CH. BY.= HYANN I S, MASS. SHEET L OF A E REG . LAND,°SURVEYOR as 20 FT... M/N. � ,ti OTE /F E/TNE%? THE S=PT/� T.4N.•C OR I`1ORE ,,E 'i � j E, .4 24'O/AM ETER CONCRETE C'OYE�:r �� I GONC4E7E , 4"Plc PIPE ! SHALL BE ,BR000/yT TO Gf�AOE.�i;,v e. COYERS�i f8 PER FT. I h+E N �R/ ECA 5 we ON COr✓ER Sf/AGI- 3E USZ- —2 7, M/N. CONCRETE r� I- IRT C'L EAN SANG �._•�.,. _ L/!�U/O LEYEL : • � -• : �,r,�, BAGxF/LL i -1"DIA. . 2'LAYER �'•- i�oo G.'tL. ' I • •j • • • • • • • p o ' i4"Pelr /ter SEPT/C TANKr- WA5HA=O ST0/yE e ,, • • � • • • • • • • a o , BOX O ? e � • i •� 8 • • • • • • ••e o' p t • • 'FEcrrve ' 314 - / /4' - • e r • • pL`PTN • • t • • . WASHED STONE 377 //3 or ha = / /3 Q • cp •e a. • • • N • • • • • • r p • PRECAST SELU�4GE j INYPR'T ELEVAT/OAFS q9c C.+c/O^y s e ,e r • !111 • • • • • • • ' e `j, o 0/7 OR EQU/V 1 /NYERT AT //V,4 ET S -PrIC TANK Ol/ p/AA?• C SEE TABULATION,TL E T SEPT/C T.a N K. 7 3 8 FT, F� I//VLET DIST/q/BUjION BOX gz Z FT• - DUTLETD/STiq/�[ITjIJI��OX gZo SECT/O/�/ O,c GRDuNO iYfJTER T,4BLE _ A q _ INLET LEAC14/A6 FT SENlAGE 01SPO SA L 5 KSTE/y LEACH//VG PIT TABULAT/ON DES/G/V CRITERIA $CAL.E D/MENS/ON R y FT. NUMBER OF 3 D/MIC-NS/ON Isy FT. BEO.?OOn�s. DIMENSION C `f FT GARBAGE 07.SP0-SAL UNIT^��r=_ SO/L. L.O j TOTAL EST/MATED FLJry_3 _GaL./D.aY SOIL Tc�ST / O/L TEST 2 SO/L TEST NUMBc.? OF L..cACHlNGs / S/DEL--AC/•!/n/G PER PIT /^FLU 99.0 /+-ELFY, So•,S pATF of SOIL TEST RESULTS 1s//TNESSED BY G'W• /`� c k EA N I .9 U TTOM LEi•4CN/NG vac.jj.PlT��t / —Sc?. FT. ?°P t- 6P PL`1'COLAT/ON R.gTE AEI TO LE TAL LEACHING 4.Q.Er4 _�L! SC. FT. �� M!N•/1NCt. ?E3ERliE LE.4CNING ARrf►_c _.5✓ FT ! 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