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HomeMy WebLinkAbout0248 WHEELER ROAD - Health �48 'VV;h+ eler.' aad° 1� Marstons Mills A 082 — Ot3 � r th UPC 12934 No. o�a�St-CoN'J�� HASTINGS, MN -® l 3 .2 i i I - I k s3 �e s '� � III i Ex Om 14 Teaberry Lane Forestdale, MA 02644 (508) 477-0653 (774) 413-7476 Fax January 18, 2018 Jay Gode c/o Frank DeStefanio William Raveis Realty (508) 280-7300 Frank.destefano@raveis.com Re: 248 Wheeler Road, Marstons Mills B & B Excavation proposes the following work as requested; • Pump existing cesspool • Furnish & Install compactable fill to cesspool, allowing it to be abandoned and meet Town of Barnstable Board of Health regulations. • Includes any necessary permitting TotalPrice ............................................................................ $ 860.00 Terms: Total Due Upon Completion............................................. $ 850.00 Respectfully Submitted, Accepted By: Ricky L. Wright B & B Excavation, Inc. r AsBuilt Page 1 of 1 f TOWN OF BARNSTABLE 05�--e LOCATION .2A0.!! Q/Of SEWAGE#239— VILLAGE /�// S.Y�S �' f ASSESSOR'S &LOT INSTALLER'S NAME,&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACIL TY:(type)2 (size) ely6l j NO:OF BEDROOMS BUILDER OR OWNEOZ 0 f�itllr�L S//-if-�.'/ oY i PERMITqI���TE. /�-� /'�-4-4MPLIANCE DATE:�¢' //-/a-09 Separation Distance Between the: , Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet i Private Water Supply Well and Leaching Facility (If any wells existFlo on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands e ais �STor within 300 feet of leaching facility) �.a�al/P(�N✓o� Feet Furnished byS i % rs 3( �� v 4.3 ,t3is�-m 211:0`mrv�3�/�© P�-6r o Aayl l( l http-.Hissgl2/intranet/propdata/prebuilt.aspx?mappar=082013&seq=1 1/12/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 248 Wheeler Road Property Address Jay Gode Owner Owner's Name -- -- information isMarstonsMills required for every MA 02648 1/12/2018_ page. crtyrrown State - Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey. _ use the return Name of Inspector —`-'- key. BBB Excavation Company Name r-- 14 Teaberry Lane Company Address �ro Sandwich ,_ Ma. 02644 City/Town - State - - Zip Code (508)477-0653 S113747 Telephone Number -License Number B.Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r ___ 1/12/18 Ins p sig�ature> _ Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to-the buyer,if applicable,and the approving authority. -**This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future.under the same or different conditions of use. t5ins-113 Title 5 0frrciel l III r¢pactim force SuCsurfete Sewage Duposai System-Page 1 d 1T r Commonwealth of Massachusetts Title 5 Official Inspection Form 1pi Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address Jay Gode Owner Owner's Name informationer every s required for for Marstons Mills, MA 02648 1/12/2018 page. City/Town .. State Zip Code Date of Inspection B. Certification(cont.) Inspection Summary:Check A,B,C,D or E l 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. 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): Septic line going to the cesspool needs to be reconnected on the interior and cesspool must be pumped and filled t5ins•3113 Title 5 Official Ns pegpn fomr SuSstrtfaca Sewage Disposal System-Pape 2 of 17 0 Commonwealth of Massachusetts -= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address _ ---- Jay.Gode Owner Owner's Name inform tio require d f f 'Is every re Marstons Mills MA 02648 1/12/2018 quire page. Cityfrown state Zip Gode Date of inspection B.Certification(cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with.Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO(Explain below): obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): I ❑ 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 pipes)are.replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1: System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 'n W 5 OlficW Ins d'mn Farm:SuMs fa.Sawaae Disp—1 System•pege 3 or,17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address — Jay Gode Owner Owners Name --"- information is Marstons Mills required for every MA 02648 1/12/2018 page. Cityrrown T State Zip Code Date of Inspection' B.-Certification(cost.) 2. System will fail unless the Board of Health(and Public Water Supplier,if.any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 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. I Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 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 Y.day flow 151.•W13 than 7tle 5 ofr e;Inp CG M Form:SWUs UW Sew D Ape '.�sGosal Systmn•Page a of 17 Vi L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address - - - Jay Gode Owner Owner's Name requiretion s Marstons Mills MA 02648 1/12/2018 _ required for every _ page. City/Town - State -Sp Code Date of Inspection B" Certification(cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped:— ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public.well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpo- 10.000gpd. ® The system fails.I have determined that one or more of the above failure criteria exist as described in.310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply El ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with:310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5m-3113 Title 5 Maw ins pealan Farm:SuSsurfece Sewage Disposal System•Pape 5 ar 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address - — _._.--- Jay Gode Owner Owners Name information fs Marstons Mills required for every MA 02648 1/12/2018 page. CitpTown - State Zip Code - Date of Inspection C.Checklist Check if the following have been done.You must indicate'yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined?(If they were not El available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site.has been determined based on: ® ❑ Existing information.For example,a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4--— Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): 440 f5i.•3h3 rNn 5 Off.W hrsp..6-Farm:.SuM.ft.6-i a Di Ili g aposal Syuan•Pepe 6 ar 17 I Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address - -- — Jay Gode Owner Owner's Name information is required for every Marstons Mills MA 02648 _ 1/1 212 0 1 8 page. CltylTown State Zip Code Date of Inspection _ .. .: D.System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): n/a Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2015 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per aey(9Pd) Basis of design flow(seats/persons/sq.ft.,etc.): ---- ----- - Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: — 151ro•3113 _ Title 5 Of.W In pelb.Fa S.Ms rft.Sewage N.P.d system•Page 7 d 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary:Assessments 248 Wheeler Road Property Address ---- Jay Gode Owner Owner's Name information is Marstons Mills required for every MA 02648 1/12/2018 page. city/town - State Zip Code - Date of Inspection D.System Information(cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and. maintenance contract(to be obtained from system owner)and a copy of latest inspection of the'I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. El Other(describe): 15W-3t13 Tia%5 Ofidel Inspection Form.Subsurface Sewage Disposal System•Page 8 N 17 Commonwealth of Massachusetts _} Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2:48 Wheeler Road _ Property Address Jay Gode Owner Owner's Name information Mansions Mills ^MA 02648 1/12/2018 required for every page. Ca7r?own - State Zip Code. Date of Inspection D. System Information(cunt) Approximate age of all components,date installed(if known)and source of information: 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 17 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): .Distance from private water supply well or suction line: >100, _ feet Comments(on condition of joints,venting,evidence of leakage,etc.): At time of inspection buildin sewer appeared to be in good working order with no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 7 feet Material of construction: ®concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: Years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 6„ — t5i n 313 Title S OftN on Farm•Subsurtem l^spedi Sewaga Disposal5ystem-Pape p o117 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address -- Jay Gode Owner Owner's Name information Is MarStons Mills required for every MA 02648 1/12/2018 page. City/Town State Zip Code - Date of inspection D.System Information(cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 1 __ Distance from top of scum to top of outlet tee or baffle 6 - Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): At time of inspection septic tank appeared to be in working order with no sign of back-up.liquid level equal with outlet invert.Tank is not in need of pumping at this time:but should be pumped every 2 y tars for maintenance. Grease Trap(locate on site plan): Depth below grade: reel Material of construction: El 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: Dare tWns•3113 Title 5 of el Inspeaian Fan:SuftUd a Sewage Disposal System•Page 10 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address — - - - Jay Gods Owner Owner's Name information is Mars required for every tons Mills MA 02648 1/12/2018 page. Cityrrown. State Zip Code Date of Inspection D. System Information(cont.). Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day ---` —� Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order; ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc): Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No 15im•3113 Title 5 Official le,owim Fortn:Subsurface Sewage Disposal Sy—•Page 11 or 1i r Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler.Road property Address .. ----- Jay Gode Owner Owner's Name -� information is MarStonS Millsrequired for every MA 02648 1/12/2018 page. - City/Town State Zip Code Date of Inspection D.System Information(cont) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above.outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): At time of inspection d-box appears to be in working order with no sign of carryover, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS).(locate on site plan,excavation not required): If SAS not located,explain why: lkti'3113 TWO 5 otrcfai W cdw Farm:Subwrfece pe Sewoga Disposal Syerem•Pap 12 0117 Commonwealth of Massachusetts 'r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address - Jay Gode Owner .. __�.._. Owner's Name information iS required for every Marstons Mills MA 02648 1/12/2018 Page. C'tY/rown .. . State Zip Code - Date of Inspecfion " D. System Information(cont.) Type: ® leaching pits number: (2)6'x6' ❑ leaching chambers number: ❑ leaching galleries number: 11 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pits were dry with no stain lines Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 111 Depth-top of liquid to inlet invert — Depth of solids layer Depth of scum layer _ Dimensions of cesspool Materials of construction block Indication of groundwater inflow ❑ Yes ® No (Sire•3113 Tlda 5 Official lnapaction Fond:Subsurface Saga Oispoaal System•Pago 13 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address ---- _ - Jay Gode Owner Information Owner's Name required forr every amtonsMills MA 02648 required M . 1/12/2018 r e _ page. City,Town State Zip Code Date of Inspection D. System Information(cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): ,cesspool must be pumped&filled 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.): t5hs•3013 TWO 5 Oft2l hs M%W Farm SuCsWr Savage Disposal System•Page 14 of 17 ICS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address ... ��God s Owner Owner's Name intormeUon to - required for every Marstons Mills MA 02646 1/12/2018 page. Clty(rown state Zip Code: Date of Inspection D.System Information(cunt.) 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 01 �.. g - s.- 0-3 -00 o* f B ?7=o I oo 4 -Ao='of d-4 V10"--4 d�fl• P � 9-s' gls�► 9-rszso� ��i(2P/Fr Ilk" Tale 5 Mull InVedan Fonn:Subsufem Smgo olep W Syslem•Pape 15 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary:Assessments 248 Wheeler Road Property Address -- Jay Gode Owner Owners Name information is Marstons Mills required for every MA 02648 1/12/2018 page. City7Town State Zip Code Date of inspection ' D. System Information(cons.) Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells Estimated depth to high ground water: >16' Teat Please indicate all methods used to determine the high ground water elevation: El 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: previous inspection report at BOH Q Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ina•3n3. Tine 5 Official In spection roan.SuDwr/ara.Sawags Disposal System•Page 16 oft) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 248 Wheeler Road Property Address - — '— - - Jay Gode Owner Owner's Name information is Marstans Mills required for every MA 02648 1/12/2018 page. CityRown State Zip Code Date of inspection E. Report Completeness Checklist ® Inspection Summary:A,B,C,D,or E checked l I ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information-Estimated depth to high groundwater ®! Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15i.•3113 rAW 5 OffloW to apeman Farts:Subsurface Sewage Disposal System•Pepe t]of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form -Z,4AZ1t1,S7*�E Subsurface Sewage Disposal System Form-Not for Voluntary Assessments g Zj1#6-E1-Et2 Ram A&t ns -f//-_ Property Address Owner Owner's Name information is required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. general Information filling out forms (�I on the computer, �1 �� use only the tab 1. Inspector: key to move your cursor-do not key.use the return Name of Inspector CAS�5�/�t/G--}� Company Name S X /7Z9 Company Address Cityfl-own State Zip Code Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails El Needs Further Evaluation by the Local Approving Authority -�3 Inspector's Signature Date The system inspector shall submit a copy of this-inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11t10 Title 5 Official In spection Forth:Subsurface Sewage Disposal System•Page 1 of 17 + r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � e 'ee Property Address Owner Owner's Name information is required for every / s /Z- page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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: 7Zr-P Zl5177v6 cSPT/c 7-,�Wk- N1� B) tem Conditionally Passes: ❑ One or re system components as described in the"Conditional Pass"section need to be replaced or aired.The system, upon completion of the replacement or repair,as approved by the Board of H th,will pass. Check the box for"yes"," "or"not determined"(Y,N, ND)for the following statements.If"not determined,"please explain. The septic tank is metal and over 20 y old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or Iltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with mplying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurall ound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old i vailable. ❑ Y ❑ N ❑ ND(Explain-below): t5ins•11/10 Title 5 Official In spection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z� w�'e4 -,�� Property Address �aya/,, Owner Owner's Na information is / r � required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) A4 B System Conditionally Passes(cont.): ❑ Ob rvation of sewage backup or break out or high static water level in the distribution box due to bro or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspe 'on if(with approval of Board of Health): ❑ broken pip )are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is remo d ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to br en or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N [I ND plain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Exp in below): C Further Evaluation is Required by-the Board of Health: ❑ Con 1 ist which require further evaluation by the Board of Health in order to determine if the system is fa=unless ublic health, safety or the environment. 1. System willoa of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not fu ning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a sa sh t5ins•11,10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Zw"!!!�/o Property Addre Owner Owner's Nwne information is /�% Srd�/T required for every page. cityrrown state Zip Code Date of Inspection B. Certification (cont.) lj/� 2. System will fail unless the Board of Health(and Public Water Supplier,if any) ermines that the system is functioning in a manner that protects the public health, safe nd environment: ❑ The stem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a su 9.ce water supply or tributary to a surface water supply. ❑ The system s a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a se "c tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SA nd 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,perform�atEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia n en and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are trigge .A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to-each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6°below invert or available volume is less than Y2 day flow t5ins•11/10 TWO 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name �,� information is ���NSGc f 02-64V /Z-3 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ( ] Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ] Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ I 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. ❑ FU) 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 flow of 10,000 gpd to 15,000 gpd. For large systems, 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 0 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen se 'tive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a pu ' water supply well If you have answered"yes"to any question in Section E the system is co 'dered a significant threat, or answered"yes'in Section D above the large system has failed.The owner operator of any large system considered a significant threat under Section E or failed under Section D s all upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. \ t5ins•11110 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 • i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Zl�0 `-�,vlR-2 �e v Property Address 6eUi-e Owner Owner's Name information is required for every page. Cityrrown State Zip Code Date of inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No [ Pumping information was provided by t owner cupant,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? El available as built plans of the system obtained and examined?(If they were not 50 available note as N/A) rvf ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑I Was the site inspected for signs of break out? (. , ❑ Were all system components, ,ex�cbdiag(�he 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)qp{►the site has been determined based on: [^�Ic.-t dv(a-v�W9C4V'aS 'M -F'-t le<2"60 9 0 �v tcp ❑ Existing information.For example,a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential F:ow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 4— DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11/1 U Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information Description: / / / G�c 4 n 9 ev,t��S�S �' V — L (20 e,Y,z�Ild-6 �� , saQ �s,�XZ�=62�q �Jvr� s-nk 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 [Z No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes V] No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date plA_ Co mercialflndustrial Flow Conditions: Type of ment: Design flow(based on 310 CM 3 : canons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Ye ❑ No Water meter readings,if available: t5ins•11/10 Title 5 Official Inspection Fomr.Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal ISystem Form-Not for Voluntary Assessments Property Address �O�F Owner Owners Name information is U5�_/, VI l� V� Z_ _ required for every _ 1V7 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) N tll Last of occupancy/use: Date Other(describe below: General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons A11 How was quantity pumped determined? Reason for pumping: 46-� 4 ��CVL(rUl ���crt 5-22,-c�7 Type of System: (� Septic tank,distribution box,soil absorption system" Single cesspool k-azt, I Y-�--yy -t V- 5t►1 k E Ire el cCrn►tec-�ect ❑ Overflow cesspool - `n 61<+" yet.✓' se hp -V—+& Ll- ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ' % Property Address Owner Owner's Name ��" information is 5�r(S M I.C-05 Kk- DZ 2` 3- 3 required for every page Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components,date installed(if known)and source of information: �#W-444' 7 IOlIU SIMd4 �A'6 L/• ,f e;z'�e?X4' Imo✓,` Were sewage odors detected when arriving at the site? ❑ Yes J0 No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ®cast iron goo PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on conditiop.of joints,v ntiin evide ce of leakage,etc.): Septic Tank(locate on site plan): a r�y>r�dP Depth below grade: feet '&MP4/w AleIA� . Material of construction: concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: y/ years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ NoIVIA �A R 1DDD �-� Dimensions. Sludge depth: t5ins•11110 Tide 5 OlBdal Inspection Form:Subsurfeoe Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle -414- Distance from bottom of scum to bottom of outlet tee or baffle / /;/4- How were dirpensions determined? rfi duff t �dof ct�1l&in4. Comments n pumping recom endations inlet and a tee baffle condition, stru ram nty, liquid levelp as related to outl t invert, evidence of leakage,etc.): �t� ���1 tj14 rease Trap(locate on site plan): Depth be rade: feet Material of constructs ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address/ Owner Owner's Piarne /IV information is 7115 11TL6S � d� �Z required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) N14 Csm ents(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels a related to outlet invert, evidence of leakage,etc.): W14 Tigbt or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth be%grade: Material oction: ❑concrete etal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: allons per day Alarm present: ❑ s ❑ No Alarm level: Alarm in wo ' g 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 tsins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is55 required for every lug page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): '[l0 tt�: Depth of liquid level above outlet invert Comments(note if box is level and distribution to ou lets qual,any evidenqe of solids carryover,any ev!Oence 9f leakage into or out of box,etc.): �eS� 'rI n 7& a,'S,//1��— �1��'I�hacarryU�er�o �� ) 2l2`'d,�•�v�.����t.�f � 6�f,�� y- �oU� N14 P Chamber(locate on site plan): Pumps in working o r: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,co on of pumps and appurtenances,etc.): Soil Absorption System (SAS)(locate on site plan,excavation t required): l �If SAS locd, y: ��5��J'��'t Q"� ���5 ��S ✓r. _ GNra/✓ld �tii�! t` L� r.i����n���ii V ° uv �, s v t5ins-11110 !� • tl `a al Inspedion Form:Subsurface �` sa System•Page 12 of t7 @I yy Commonwealth of Massachusetts_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address �tod-2 Owner Owner's Name NN qq information is 16Y56s required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: �T— po leaching pits number. J �10 ❑ 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, lev I of pon ing,damp oil,condition of egetati ,etc.}: UY�) ��Lt � �"Y1rsr�) Cesspools(cesspool must IIb//e pumped as part y�""of inspection)(locate on site plan): N tuber and confi uration W I�G11(�iy�S-Vvt tc.0 (r d,t( r.JZ-��l E �o .e� �nm+-,�twk-tc> 6"�- (� Q Deg(h—top of-liquid to inlet invert 1 S D� �e'0-5 ro I da,tt w��atC r. cr>Z/ Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes No t5ins•11110 Title 5 Official Inspection Fomt Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address r �v� Owner Owner's N e information is , Mrl A t r(S �9 1 Z— 13 required for every 6 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(n9te condition oil,signs of hydraulic failure,levelof�pon ding,condition of veg tation, etc.): - C T� lie P (locate on site plan): Material f ccnstruction, Dimensions Depth of solids Comments(note condition of soil,si of hydraulic failure,level of ponding,condition of vegetation, etc.): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. e`Z LAD4F(-�2 Property Address Owner Owner's��?a information is Iy �6i$ required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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: Tb hand-sketch in the area below ❑ drawing attached separately 170f i!v t'W t z2'-0 t3•-Cr 40, k C�now� I�J -4 aL(- 13-4 S (02=4" -S 52'-d' G-S G3'-art ow t5ins•11 M O Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /41 Property Address 6�ov�- Owner Owner's Na information is required for every page. Cityrrown State Zip Cade Date of Inspection D. System Information (cont.) Site Exam: Check Slope [3/S/Urface water heck cellar zooz' [-thallow wells Estimated depth to high ground water: feet�� Please indicate all methods used to determine the high ground water elevation: C ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date J LySd fit bt�t6ng properly/ob �tion hole v►rith 150 e t q�SAS) �-- td-�'IQ ❑ Checked with local Board of 1-14alth-explain: ❑ Checked with local excavators,installers-(attach documentation) ^F�( Accessed USGS database-explain: V q S 4 ' You /must deescribb how y to lished the high ground water elevation, elevation, �7e ';-Af' Before filing this Inspection Report,please see Report Completeness Checklist on next page. f5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Z Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System. ..Foorm-Not for Voluntary Assessments Property Address Owner Owner's Name ,1 information is required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A,B, C, D,or E checked / ] Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins`11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System`Page 17 of 17 rr„ COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION /� Try .$��hTg Bc Property Address: �Z� !�l//fP.�/y l '� /CGS Owner's Name: ,9.V9X o0E Owner's Address: 1D4 Zgzo L7RIVOs' Date of Inspection: 5 z/ — S 2L 0-7- Name of Inspector: (please rint) �0w4VZV �, y764✓Gr Company Name: Le— -5— Mailing Address: D oX /7 ' �i5�a✓��/ r OZ-.5 6 _2 Telephone Number: v-tine-g46�9 Fps-P?Pv -Z,4-96 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is,true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR '15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails cTr SIInspector's Signature: Date: S ZZ UCD ``• c The system inspector shall submit a copy of this inspection report to the Approving Authority Ea and of Health qr-� DEP)within 30 days of completing this inspection. If the system is a shared system or has a d gn flow ofd 0,0 f gpd or greater,the inspector and the system owner shall submit the report to the appropriate regt nal offic?'of thc/i DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approva� authority. w t— Notes and Comments s' � r G �� * ** his report only describe 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 i e� Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTI/FICATION (continued) Property address: u Owner: Date of Inspection: S-ZZ-O9 Inspection Summary: Check AB,C,D or E /ALWAYS complete all of Section D A. :7�have asses: _ 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: EN7�/2E s Tl�t/( /� ��� �•�Lltiyb Dif�'R B. System Conditionally Passes: One more system components as described in the "Conditional Pass" section need to be replaced or repaired. The sys , upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determine Y,N,ND) in the for the following statements. If"not determined' please explain. The septic tank is metal and over 20 s old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfi tion or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic to s approved by the Board of Health. 'A metal septic tank will pass inspection if it is structure sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water vel in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. S tem will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). e system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I . Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTInFICATION (continued) Property Address: 9 4Qe%+- Owner: Date of Inspection: S-ZZ-vim} 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 fail to protect public health, safety or the environment. 1. Sy em will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the syste is not functioning in a manner which will protect public health,safety and the environment: Cessp I or privy is within 50 feet of a surface water _ Cesspoo or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the and of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner at protects the public health,safety and environment: The system has a septic tank an oil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a sur ce water supply. The system has a septic tank and SAS an e SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is s than 100 feet but 50 feet or more from a private water supply well". Method used to determine distanc "This system passes if the well water analysis,performed at a DEP rtified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free fr pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less th 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fo 3. Other: 3 r Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: G✓�LP/���Cr jlrys ��t Owner: l7o C Date of Inspection: Z2�0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No � I, V $aEkup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool ✓ kiquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped . ^portion of the SAS,cesspool or privy is below high ground water elevation. 7g- ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface i/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. A& Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Ae,o' (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. All- E. Large Systems: To be c red a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either " r"no"to each of the following: (The following criteria apply to larg tems in addition to the criteria above) yes no the system is within 400 feet of a surface drinktn ater supply the system is within 200 feet of a tributary to a surface drinking ter supply the system is located in a nitrogen sensitive area(Interim Wellhead Protects 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, o swered "yes"in Section D above the large system has failed.The owner or operator of any large system considered significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: '"446 P✓ AW 7lK/l LC f Owner: Date of Inspection: s-L?- a-� Check if the following have been done. You must indicate"ves" or"no"as to each of the following: Yes �o Pumping information was provided by t e owner ccupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks V — Has the system received normal flows in the previous two week period? v 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,;9cluding 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 cor..struction,dimensions, depth of liquid,depth of sludge and depth of scum? ✓th_ Was the facili owner d 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/�o '7 V Existing infor'mation. For example,a plan at the Board of Health�W ?� — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 1 1 / ) A��StJ��4eon�`���7e� �i —Plel 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �_4440_ LL Owner: OOE Date of Inspection: _G FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): ¢- 7C� 7 �� DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): Number of current residents: 5 i Does residence have a garbage grinder(yes or no): &� ��/s � 14U-r)t k- Is laundry on a separate sewage system(yes or no)-Al- (if yes separate inspection required) ( �k L"`^y P%'o vt d-e,:4?by Laundry system inspected(yes or no): �//� ��a la'� ( F ?, Seasonal use: (yes or no): /l/o �� � U� G Water meter readings, if available last 2 ears usage d t��T S , ( Y g (gP )) �I' Sump pump(yes or no): 4/0 Last date of occupancy: �U✓/'�j� CO MERCIAL/INDUSTRIAL Type establishment: Design flo-w1ba5ed on 310 CMR 15.203): gpd Basis of design flo ats/persons/sgft,etc.): Grease trap present(yes or Industrial waste holding tank: ank presen or no): _ Non-sanitary waste discharged to the Title s m (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: d�✓ 'L Was system pumped as part of the inspection(yes or no): res If yes, volume pumped:laaJ gallons--How was quantity pumped determined? Reason for pumping: kn e�c T F SYSTEMptic 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 1r Other(describe): v �¢-.LIYA a'— Approxi of all components,date installed(if known)and sour a of informa�n:�avv�x-sT 8x� r74- e sewa a odors detected w en arri � / 01.6 g tng at the site(yes or no):X y 6 1 • Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 44 Property Address: Z115 Steil/! c� Owner: Date of Inspection: S ZZ- Uq BUILDING SEWER(locate on site plan) Depth below grade: 163 1w61,9&je Materials of construction:_cast iron _ 04 PVC_other(explain): Distance from private water supply well'or suction line: Zoo Comments(on condition of joi/nu, venting, evidence of leakage, etc.): d� `r`7�; (,yajt SEPTIC TANK: (locate on site plan) Depth below grade: �b`�,b /Z"G��u��T R/5�11��"�'w,�1 ✓c') Material of construction: oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:IZIA Is age confirmed by a Certificate of Compliance(yes or no�-�4 (attach a copy of certificate) F 0 Vevel'l1,4-& Dimensions: .y-Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle��'- �N� (=Z!33 �y Scum thickness: Distance from top of scum to top of outlet tee or baffle: 4 Distance from bottom of scum to bott&of outlet tee or baffle: Z 1 How were dimensions determined: Do�VW Q-]1 -- Comments(on pumping recommendations, inlet and outlet tee or baffle condni tjpn structural integrity, liquid levels as related to outlet invert,evidence of.leakage, etc.): ai�1`i�t/ J`t/�S do�s�e, if/� a c95r�vr.� or»,�,Qc v c �? ve c (/dam r /ti .tL114- GRR TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_co to_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, �cturality, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 s . Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / /SYSTEM INFORMATION(continued) Property Address: tu! Owner: ®E Date of Inspection: U� TIG T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below e: Material of construct] 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.): � � o✓Z'�4 v3 ,,,1 zif73.36DISTRIBUTION BOX: present must be opened)(locate on site plan),j5g-- /X �� C3//,v 9 -/) Depth of liquid level above outlet invert: Comments(note if box is level and distribu " n to o tlets equal pny evidence of solids carryover, any evidence of leakage into or out of box,etc.): V ���/ ,(�D&'�i1/v i=ui/�G�l// S f►'�� l d Q l� av c� PUM MBER: (locate on site plan) Pumps in working order(ye Alarms in working order(yes or no): Comments(note condition of pump chamber, con i umps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: S ZZ-O SOIL ABSORPTION SYSTEM (SAS): t/(locate on site plan,excavation not required) 4f SAS nf-located oqi Y: Re�A/� �'1 1.��® m1 z ca/s 4, Type "�l,z� f215C�2L � �'�P �5etli t�leaching pits,number: leaching chambers,number: , "� o G `' ^' o IN V leaching galleries, number: �a—f0 G c, o -, �, s 1IP leaching trenches,number, length: leaching fields,number, dimensions: ciQr � overflow cesspool, number: innovative/alternative system Type/name of techno ogy: n I Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, co it ion of v ge etatio , etc.): ��YyJ �� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and config Depth—top of liquid to inlet ' ert: 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, leve �onding,condition of vegetation, etc.): PRIVY: (locate o Ian) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failur , vel of ponding,condition of vegetation,etc.): 9 f i . Page 10 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: orl �y�QP Pam ✓ f Owner:Date of of Inspection: ��dG SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benc:-lunarks. Locate all wells within 100 feet. Locate where public water suppl enter e building. .r Zoo � ---- L ----- ---- ------ - _ __ t ALP. t.P �gS(rlenQ) a f� m Si- AW ' 74, ilt'7gq 27 _ U -3 14U 0 T-- W7A 10 r •: Page 1 1 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope / Surface water o/!''lla Check cellar 11'7 f v Y cra�✓/S�c� e�vY Shallow wells —c C. 170�Q yr YV {ivy ti�6� �-J v� Estimated de p to ground wate>-19 feet 4vvnj /1iI���✓���tcf } 2�a t �l�,� �� -�,�f -4-r1orV-h Please indicate(check)all methods used to determine the high ground water elevation: -O btained from system design plans on record-If checked,date of design plan reviewed: served site(abutting property/observation hole within 150 feet of SAS) llde 11,,,S f✓ ►��( Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation)/ / ✓ Accessed USGS database-explain: Uf6s�fi9� ��' / Ay'4/4c Z1�v 4v. o fis4-s You must describe how you established the high ground water elevation: zo, ,G z�,Z �z� r�,� ` e v-4�1VOw-t W,71 sere.e rev g3.59 t4`' �`(X � �2�42 �' l�'(Rts tw✓ ,o•• e�v7l•sg�-w�� �R��7!•7 O W✓= lo.i�S v c� v v ( ��f,Q�v� •'Zb (p� 1D" v a O Z) - 0� a 4 o o v V/(ef, v Zo � � 30. tlo.g� 5 � 11 4 V 'lit N0.. =.63 Fim.B THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........... -----------...................OF............................................... •-•-.... Appliration for Bispaoal Works Ton trnrtlun Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - -v --- ....................•--...•....... ----•-•---•-•---•----------.........-----•. . ----------..............------------ ocation-Address or Lot :�o. ................................................. _....._' ---- .--..---- ._._/ w -` ............. =.. ?� � Installer A ress �D �� ry _ Type of Building Size Lot....................C--/-----_Sq. feet Dwelling�No. of Bedrooms..3....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons.............•.............. Showers a YP g --------•------------------- P ( ) •— Cafeteria ( ) Otherfixtures -------------------------------------•----•----•----......------------------•--------------------------•--••._--_... -----•---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. � Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length......... _____._- Total leaching area....................sq. ft. Seepage Pit No.__I-_____________ Diameter. V,_/p_... Depth below inlet..6.............. Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................•.............._..._......._.._........... Date 1 .' .f Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water____-__--__-_-----__-_--- f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._________.__..__...___. O Description of V ------------•---••••-•-•-•--••-----------------------•--------......--•--•......••-------.....-•-------.....--••••-•---------•---....-'--•-•----------••-•••---•-•-•-••--••------•-••-••-•---------- W ----------------------•------••••------------•------------------•---••••----------....---•-••-•------•---- ------ G� U Natur of Repairs or A erat•ons—Answ r when app i able._ _____ _____________• -_-__-.._-•----.---.---___. . ----•-----•---------------------------------------------------------------------------•----...----•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f"iT l-lv� the provisions of i1I:..- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has#beenissud by e 8oard o'1 lth.Signed•• . ....... - -"-'---------------•-----......-•••-•--•-- �1 y Date Application Approved By....... - ------•------------------------- ---•---- Date Application Disapproved for the following reasons:----•-------•------------------------------------------•--------------------•------------ ...................... ...-•-•---•-------------------------------------•-••---------..._..-------------•'-------...-•------------•-•----------------------•------•--------•••---------•-------••---•-------••••-•-----...•-•--- i q c� Date Permit No.... .............................. Dstz •. .yam FEs....... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --------------- -----------------------OF.......................................------.....__..... Ally irFatiun for Dhip sal Works Tonstrurt"tun Urratit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal -System.......................a q � -•--'••---------------------------••------.. .......------.......---------- .... ... (f ----- ovation-Address or Lot :�o. .�...:.. - .... - -'--.....-•-----------------•••........--•.....__... ......---...._........----.......'--'••........._........... _...��� i O e G+ ��eV / ._.t _. W ---._�,/._' . .. ...........�.�.� - ' ....... Installer Address Type of Building Size Lot- �.d_l� ....Sq. feet Dwelling�No. of Bedrooms___.Z....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g --•--•--•-----------•-•----- P ( ) •— Cafeteria ( ) dOther fixtures ..---•-----------------------------•-----------•----..._....------------------------------------------•-••--......•. ---••---•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length..___......_.__... Total leaching area....................sq. ft. Seepage Pit No..._j-_____________ Diameter.3?-_.V_.6... Depth below inlet..6.............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... ,4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___-••_____--___--_____. 04 O Description of Soil ------'`mot=t '-•--e'...---------•-- x W -•••------------- ---------------------••••-•---••••--••-•-•----•--••••---------------•-•-••---...------•--•-- U Nature of Repairs or Al erat'ons—Answ,gr when appli ble...�_____ ___._._1 /----------- ........ . ...... .................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Ti Li. p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu d byte board o h lth. Signed...,E -f....... ---- �1--'..1--�-e-•�..w...--- _ Date Application Approved By................ .._�,-=3•--- � . _ .} ..------'`�_ fly '-- ------ V Date Application Disapproved for the following reasons---------------•-----------------••--------------•----------•--•----------------------------•-•----------.•----- --••----...•---••-•-••....••--•••---•---•-----•••----------------•••.....-------------•'----••••......._--••-•••.._.......---•-_...•-----•-------•---•••-•••---•••-•------------•--------••-•--....----- Date Y� Permit No.---- --�=--�°��............................. Issued_.. ....----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �j .:..........OF................ :, .. ,a�,.-A Q th!. ............................. uEnrtgfiratr of hunt li�tnrr THIS IS TO CERTIFY, Tat the Individual Sewage Disposal System constructed ( ) or Repaired / A ,,4 /y�'I/�nstallfe�r/� at_......_... d' j........&_A4_11---------------------------------------------------------------------------------------- has been installed in accordance with the provisions of T I T IZ' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------- `"�(.._(�. 5'.`�........ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUE® AS A GUARANTEE THAT THE SYSTEM WIL U TIO S- TISFACTORY. DATE.............�--... Z...........----•-------••-------•---- Inspect -- �� ----------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD O/F� HEALTH .......... (..l:a.........OF..............IA-nI Q ? .............................. �J NO.. FEE._(y!� Disposal Ivor ii T�ung union rrtntt Permission is hereby granted. -�= --- -----•---r. ------------------••----------------•-•-•-••-----......-•-......._-----....... to Construct ( ) or Repair ( an Individual Sewage Disposal System atNo.---------- r -�1 � ..............t ......0--m...............-................................................................................ .. Street �y C� as shown on the application-for Disposal Works Construction Permit No._ -l:&_t1-- Dated................0......................... ............................... ----t -------------------------------------------------- DATE................................................................................ Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS '777 No. YmB ................. THE COMMONWEALTH OF MASSACHUSETTS 01 BOARD OF HEALTH ...................... ....................OF.......................................................................................... Appliratiou for Uhipviial Work,5 Tonotrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ............................................... .................................................................................................. ion-Address or Lot No. ...............................................Owner.......................................... ..............................................�W�res.s .......................................... ......A ...................................................... .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......... Expansion Attic Garbage Grinder Other—Type of Building J�--------------N_o-------of----p-e-rsons............................ Showers Cafeteria Pa Other fixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width........___.._.. Diameter................ Depth_....__......... 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.......................................................................... Date........................................ ,.aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......__............_.. 1­4 �Tq Test Pit No. 2..............minutes per inch Depth of Test Pit.................... Depth to ground wa er........................ ------------------------- -----------*---------- Ix ...................?.............. .......... ----- .....---------- 0 Description of Soil... ................ ................ .... ............................ .. .. --------------------------- ---- ------*............. ... ............. ........... ......... ... ...................... ........................................................................................................................................................................................................ 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 TL Ili U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee .ss by th ar of health. he.d.......T .......... .......... .............................................. ................................ Date ApplicationApproved ....... .................................................................................... ....................................... Date Certificate 0 Compliance has bee -ss by the wa er------- f. ....... ...... ... ........... .. .... .... .... . ned.. ... . ....Approved ........................ ........................... Application Disapprov the following reasons:................................................................................................................ .............................. ...... ................................................................................................................................................................ Date PermitNo......................................................... IssuedL....................................................... Date Fns,Z3.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------------ - ----.....................OF......-•----........................... ..... . ppliraiion for Disposal Works Tonotrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ,�#8 0UfjE_FLP'R )e Ab ..........................-_........_. ...............------............................... ......-----...-----...----....---------------•----...........------............................... /+ �. G6 attion-Address or Lot No. .........`.................y..............................._........__........................... ..........__................................. .._.................................................. Owner Address a FUL L�<. ...... ----------•--•............... .......•----------....------------.........: •---.._....-----------.._...:---•--------......_.. Installer Address - UType of Building" Size Lot............................Sq. feet 1-� Dwelling—No. of Bedrooms.......... .......... _ _Expansion Attic ( ) Garbage Grinder � ) a yp g � > No. of persons............................ Showers ( ) — Cafeteria ( ) Other—T e of Buildin Other fixtures W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons' WSeptic Tank—Liquid capacity............gallons Length................ 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--•---••---•-••-----•-•-----•--•----•----••---•-----••....--- Date-----•-•----------------••-••---------- �4 Test Pit No.. 1------- ......minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 1. ...... _._..minutes per inch Depth of Test Pit.................... Depth to ground w -_-_•_---•----•-----.__. a' ..................r............... O Description of Soil .... { --------•--------- 1 w -------------- --------- ------------------- - x ----•------•----------------------•-••••--•---••••••-••----------•--••-----•--•--•••-....----••••••-••----•--...........------------•-•••--•-----••-•------...---•••......- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------•-----------------------------------------------•--------------------------......----....------•-------------------------------------------------------------------------------•---._.....-•-•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the ar of health. Date Application Approved ....... ---•••----- ---------••-----••---------------------•---•--•--•--..-- Date Application Disapprov the following reasons-------------------------------------------------------•------•---------------...--•----•-.........•......_._._ ------•--------------......................•---•------•-•-•--------•-- Date PermitNo.................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF.'-:HEALTH ..........................................OF............................................... ...................................... ,.l Trr#ifiratr of Tom fiuure rPfS Ifi� O CERTIFY, That the In vidual Sew Di osal System constructed ( ) or Repaired by =�� ._. V. ._ . 7-i- --•--------------------•-•-----------.------------------------------------------ ; a has been installed in accordance with the provisions of T T 5 o tate Sanitary-� ary o a a ed in the application for Disposal Works Construction Permit No.- .... da.ted_.�..:r. - ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... 4 .- ••----•-••----•-------------------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF................... No......................... FEE........................ Disposal rrutit Permission is hereby granted.......1 / -•---------•---------------------•----------------------------------....•-•-- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo................................................--.................................................................................. Street as shown on the application for Disposal Works Construction Permit No........ ":__ Dated.......................................... -----------•-----••-•---.... ....... --------•--•-•---•---•--••...•-----••--•-----•-•-•--•-----•.--._-- J� L Board of Health DATE --------------•--------......----•••......---• FORM 1255 A. M. SULKIN. INC., BOSTON i �' ,fi3 , .«r, ' - r '<;{� a a f.^ 'ayr� 4F „F•ret ,' _ t . � -• �, t „ NO V, S '{+ � {. ,,. - .. ` F ,s, r. .�,t, ✓..._ t . '. .j '4 � yr` r'-�a. .,.I r r.^a,'r K< � LS'- '� r.e _:h d , �, t a .k{ 3 ...•v ,e � ., f Yr � r } ..�4 a ;, •! r 2 � r.; �'r `r« n •. c �:;s, ' ,,{ , ,� '! 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' v+ da •x 'YC a + ' 9 •Y i«, p t f<q -F W� f `+...i, r'�+:L t'c,xrk +,, i"� s ^+` ' C ".✓ .. a ,f i t 3 +y<, t i 1 t r . .r r - x 4 °r 4r :v+J"•; {1 n dr Y t ya Y i-`' r .� try• 'x' s y ; G- f, '� r t•t!.'� wi .,a r -`7 r '` �..,4« s `«s i fit `'�M� t+`-' -•`allx rrf.. ,• T fl., �t iss ``ty .'s rY.". � 4. kf. h• � r '..p l y�:., � rk �""':.. t s ,Y'S« +a. " ', ' J + �� � � � . , � i� 4 .r K t S y°,,,. �y,�'E`,�%�t Ay �:` ..► z' •.V c)�«}�kt v- a� y., , tlR. r Ir .n''� r"A• '"�' z r � ' •'1 ,,�+ r A y f' Yt f > " r4..l }� . 4F r :� .. r p+ '* ,(YY � y, ,t, J 3 t!. •r,,+ i' Kt ti.ti' <� } a>�r r J;^ra: ^ a, ( alb y y.t Lir, •r. 1 i< •,1.�'+' rt �. ,"{, xj` '+,� T<$t"� ' ��_,. « r` Mr A J. Gode.:- 248 .Wh®eler YRoad y �, -` r L, i •, ; ;K > ` ,t•, I r r Marstons"Milli, Maa­'02648, ' r d �P• L,. `t } 3" r�'}Mt + �{ r «� * aw `e L•.,7 r tia 1 •, a.: r.r, a ` .t ;, `•i: :} ,.t r. ;v ,Y?krs �v '4 ,r r� . rr , �. :r"� } r f`+n? -r, a.r,i p t �, i '.�r .uY' •.� A a t f.� 1De r-M a r. Gode i ' r .ti ', . } t t y_. •7 r -,.;t y 1. "dr F A. .�., � Jr+C d L v. t r. +'? ' :' '•�r�r t •, - 1 '' C ."�f: 11 vi. r ;? ..•i a.i a 7, •'. r i �' t i ',You• are granted s}variaiice} t jnstall a weil 120' feet .from an exisrting� „ra. ''septic ':leachingrpit at 248 iheeler Road, Marstons`:Mil�ls,~in' lieu,of the required' 150' feet s with tti f fi ' q ,., a ollowingrconditi`ono ' 7'.Z �'- _Fri., � � i..y � ..�{�,�. ,�'� ''x. .. t i'` •• { a r.I` s r � V.. ` ~.� tr , . .�. . ti i ,+C .(t � s 6 rt-:�: a��, ..,''r� .x,} '�• ;' ,.'4 -. 1 s ;.^- * ,�F (1)w The existing<;on ei'te sewage .systems musts be 'inspected',bq a.licensed�.� is , y ,} T disposal works :hstaller4nd ver&-fi d fiat they" .• a ,t Meet -the;requirements , '" of T tle S =of i the rState Environments Code R a `' z V . 1 , nd theiTown if `Barnitable` HealthtRegulations � "` "P ..< ra '- ' Fv a_ V. .r<'. . a �a5«- s.Y ti, !^. L.a <,M!, .'+°'•� r• « 7 <Y ,a' t: v. ...F«• f r"• r,y~t •'� "r.-y c «,, r+ ,.r«a. �.t- �a ,. d«ro �" jC '.'"i y,. > Y 4. *`• i n Al ('2) ,A Disposal Work`s;Construetion Permit must be��obtained -by a :licensed i inst5A�llpevfor: the:proposed additf©nal system: r , . "r r�. 3,} "�b �r}r Ly„ d " KS' " r�' ti iA S ,�p } •t�„ a r4, �-•- �• -.3. r 4:'k �. C.G,,�a?rt- a'r"r9 I #' '�" b c'tR, t°,�}' a .r i y a y ej • i �t{+ t as.. "- "' (3) The water from Chen new'`welly List be mate' for xb to t d ac ria and" z , 'ctiemical:s#-pr qr twany,fdome+atic u`se `and must;meet" alb orf the �;;�+'x�, ' 4� k "at'`di rd.s 4 .b thking..Act; �(tS�: +i �� � `i•�•(, r�' •.i ,�. A�t..,, -..'a,ti r ~.$r�T 1 v x� .••'� •r; re ti {ter ��� J.''. W'r a''�. This variance expires December:l, 1985. rr •r'�° ' / 1 i •3 +4 �c: 'r.�• - +`r s P«,,,^..�� n y yt t a7 i ; wt. •'" !`t' � w� �.+c+l. � +. i t y"rAr? �<�' � «. •} "y �' 7 , r i +Y' c x ^•r.,,• , - tv. {•G•:. t* t v y. t t '} t; �.4 �""r•tr `���: i x�.�, -.+. ..t t , p K � i.`�^41' �-. r �K' �3:M. 7 y p Verp truly. ours, , r�r t •}H= � `3 � «. � ,� �.�*;„ , r3, � ^ ,��« , t ` 4�wk4� yV ,{+;, g.rr... y ;. ,.M t k• •,5 i,!`,', i ., �'� a- ! ; r a ` L { )J .t '4I= f ..,, '•r ` `_ ky ,r. y i•^ '` ,Yy�. �7st� r: V'ti_ ,r •:. L� .f i ;.'•.1}k. t = r 1.r`�,,. T t�� ty, * f� {� �y� � } �,ry' > , r x y, ! ;iC � � ,• `. A 4 r:<. obert La.i.rCil{i lds �t- .,fE 'wn:.f, F .i f ♦ 1}ir,y,`t 1. # +,4;« J �jJ« Y r,�J•.. �. { },ar s .. t, y r < = CHAIRMAN irvso r T.e�,�' `L s'*r# ? v w �~ ';< i _"!��Y �. 4 y ", _ , a OI.6, e r ,yi'• y / -BOARD Or+ ilEL11}l i►* .4F , r •$ � c '. +'fs e , t 'c'. a r :: c L. + C. r-., V IY " i. 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A 3 - 1,". f +.- r V -'ter � "aj'ea r � y .z la y �`,.t �5. ,.J�M � '+'y`�,.y..,r }r fit. �r �1•v'* �T, � t it _t•` -t't,tJ' - h �' ,x*� .�`. ''� � � A ti`t'a .i�L.. a't- 'c.. + r � �r. a .�I:,»r } r .+,>.< rz :x' ' t f't " x ,�'i >.' rsS�;. s�$r'r�t-F" S v: a t'. s r3`V v {,_ "c• s ,•} .�.�;' i �•{r' r ,��,. y •- `+,� �: 3'iS ♦ e�}{j.fir,.,A + .�'� .5r,k'�'�; i,': d a} �e�}J� r'k^�I r rt. lt.,�''� sr � 3• �4 t ` k s f• ti.tr' °+ �4' �£:: t'A �����, z. �i q•,� t t � P .,b�,�,f`��, di` t w a °S, 3q� v t .t- t: 4 w� V ^ter 4 i ;,_ ,t ±�r tr -.: � ..A i "` t `,. a+: +r} t. S r,{. .�'' !�. .�'� y y�r*,� � �•y's rl :� e r..a, �t ea:'t�' ' ' + ,r•.,Sr a /;4.r +zd.� f.FE — --- ON 7He To TOWN OF BARNSTABLE �Q rr o ,,« OFFICE OF BAEESTSLLL r�.a� : BOARD OF HEALTH %y � oOpTfD HRY 367 MAIN STREET HYANNIS, MASS. 02601 VARIANCE REQUEST FORM All variance requests must be submitted five (5) days prior to the scheduled Board of Health meeting. NA. IE OF APPLICANT (�?1� �. I- TELEPHONE •NO. `7 1-0 dy`� • ADDRESS OF APPLICANT NAME OF OWNER OF PROPERTY JE LOCATION OF REQUEST �� � v d(fE VARIANCE FROM REGULATION (List regulation>> ` VARIANCE REQUESTED (Specific request) �0CX'77r F-w AlkGL IW714 F*(S 7N'6 6077c 6K(7-0# N vVS7Z�W 7 r5 J &/ / � Ce-D-s REASON FOR VARIANCE (May attach letter if more space needed) �(IYLL Ala? r PLANS - Two copies of plan must be submitted clearly outlining variance requested. VARIANCE APPROVED NOT APPROVED REASON FOR DISAPPROVAL . Robert L. Childs, .Chairman Ann Jane Eshbau gh pf H. F. Inge, M. D. BOARD OF HEALTH TOWN OF BARNSTABLE y i a 1 r' l CI F # t ..�� 11 P Uk r A-k E-H Pf, GF'ostD �DDiT-70N \Rl -14,Ll ' i CAkPG f r wit ! v � 1 � iss. IN r�r '