HomeMy WebLinkAbout0025 ANGELA WAY - Health 25 Angela Way
W. Barnstable F
t A =- 133 074 _ v
L
0
TOWN OF BARNSTABLE
SEWAGE # D03-S a
VILLAGE 1-31*9R ai/STa� � ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.AfZC h'
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type ) S^�D H' '���� (size) -� s x(3 X '
NO.OF BEDROOMS__ _
BUILDER OR OWNER J � f" /— `J 6 -s
PERMITDATE: Ire ZS 3 COMPLIANCE DATE:_ 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
1/J
T= 6/7
.8 17s
7-7
Nf 7
No. 3 _5 Fee s
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for Mioponl *pgtem Congtrurtion Permit
Application for a Permit to Construct( . )Repair( )Upgrade( Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/ ,cel `
43
Installer's Name,Address,and el.No. Designer's Name,Address and Tel.No.
s-�y �7 s �36� s� � 3�a a 5•� �
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder(/W
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �a gallons per day. Calculated daily flows~/. / gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �''d S Type of S.A.S. 3J S'o e C,4 n ye A r
Description of Soil
Ngture of Repairs or A terations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the Biai
5 of the Environmental Code an not to place the system in operation until a Certifi-
cate of Compliance hass of He
Si
Application Approved Date
Application Disapproved for the following reasons
Permit No. 3�S Date Issued U
---------------------------------------
T7
5 5�
No. �� 3 �w Fee
, THE COMMONWEALTH OF MASSACHUSETTS j rEnteired in computer.
�� �.
PUBLIC!HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipprication for �Dioozal *pgtem Construction Permit
Application for a Permit to Construct( . )Repair( )Upgrade( Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.A
A Assessor's Map/Parcel
/3 3 7 a S' �•� - GvAr G� /�.2 .-�.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
9 4- �, SST e�
Type of Building: 1
Dwelling No.of Bedrooms G Lot Size �sq.ft. Garbage Grinder(V
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow c gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /J b d S T Type of S.A.S.C3] S`a a C`1l3 rt Yer A T
Description of Soil,
S C ei
� t
Nature of Repair's or Alterations�(Answer when applicable) /S o'6 S i 1� o X '
�3� s oa �.fr� •MF2s 7
Gr/ ' sr� S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue of He
Sig ed r�� Date
Application Approved b Date P x `
Application Disapproved for the following reasons
Permit No. Date Issued JP-r A0 3
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS .
Certificate of ctCompliance ,t
THIS IS TO CERTI]EY. that the On-site Sewage Disposal System Constructed( )Repaired(x )Upgraded( )
Abandoned( )by X a- " ''-/
at' a _5- OQ a—,-� r/-9 A/ A > a/ zl e)"Z has been constructe o in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2-003- 6'2( dated /G Z 3
Installer 2 e/J l vsj �r Designer. JQ;W A c / ' ,, y f R
The issuance of ' pe 't shall not be construed as a guarantee that the system wr: � 1'oWsi ned.
Hate insYec�or ��, • .35
No. 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
niw!w *r5tem Conotruction Permit
Permission is hereby granted to Construct( )Repair.( )Upgrade( —)Abandon( )
System located at c 2 A 4ed14 /?,9 rt w 5T/Y�-2
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the dat of this permit.
Date: 161&f o 3 Approved p
PP Y � .
FAILED INSPECTION
D ATE 719103
PROPERTY A (DORESS: 25 Angela Day
-----------------------
-- 6)e31-—Ba2n.6.tagie, l' zz.--- )/ - e"-7�
02668
On the above date, I Inspected the septic system at the above address.
Tnis system consists of the following:
1. 1- 1500 ga22on zept.ic .tank.
2. 1-Dizt.¢.igut.ion Sox.
3. 2- 1000 ga.0.Pon /22ecaat .eeach.ing /?itz.
based on my inspection, I certify the following conditions:
4. 7h.ia .ih a t.it2e Live zept.ie �3yetem. (78 Code)
5. The eept.ic .syhtem .iz .in hydaau2.ic ./a-i&ae.
6. A new Peaeh.ing azea needz to ge .in.6ta2.2ed.
7. Both o� the ex.iet.ing .beaching /2.itz ate .in �a.i.2u2e.
SIGNATUR
Name : J . P . Macomber Jr .
9
Company : jQ,tpn PI_og t2tr d_ Son, Inc .
E
Address : ------- 2p0�
_(-ejueLYLLLe-,_ PJa _Q.2-632-0066 ;Nei
OW NEPt
Pone : 508- 775- 3 ) )8
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
IOSEPH P. MACOMBER & SON, JINC.Tanks•Cesspools•Leachflelds
Pumped & Installed
Town Sewer Connections
P.0 Box 66 Centerville. MA 02632.
775.3338 775.6412
COMMONWEALTH OF MASSACHUSETTS
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
Property Address:25 4ngeia Clay
0ezt Zfaan3Za97!e, 71azz.
Owner's Name: ue enn t
Owner's Address:Sarre
Date of Inspection:_
Name of Inspector: (please print)ao,6el2h P. (7acom9ea a/t.
Company Name: g. l. Nacomgea 9 Son Inc.
Mailing Address: 13ox 66
A, 02632
Telephone Number: -
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
,Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 2kA66ie--Z1t
Date:
The system inspector shall s it a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address 25 ,4nge-a Clay
Vgzi 13a2njtag2e, Ma.6.3.
Owner: .0 Ij o T o n n i
Date of Inspection: 7/9/o 3
Inspection Summary: Check A,B,C,D or E/ALWAYS-complete all of Section D
A. System Passes: �4)_d)
AI 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:
lfoth o, the .2eachinp 1?.i.tz ate .in hydaau2.ic �a.i.2uae. A new
lPonrhina rinv<i npv A io gg ia,3taiied,
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
BUD The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
4/0 Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 25 Ange ea Way
e.6 a-an a e, a.6.6.
Owner: SLLe 7enn4
Date of Inspection: 719103
C. Further Evaluation is Required by the Board of Health:
A�D 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:
d76 Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
NO 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.
,Qd 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.
A�D The system has a septic tank and SAS and the SAS is less than 100 feet t 50 feet or more front a
private water supply well". Method used to determine distance f��.rZU
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 25 Anye.ea Clay
Wpnt 2n e, aza.
Owner: Sue 7enn.i
Date of Inspection: 719103
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backu of sewa a into facility ors stem component due to overloaded or clogged SAS or cesspool
Discharge or pon ing of effluent to the surface o t e 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 A, A j4vr5
Liquid depth in is less than 6"below invert or available
q p 8esspeel volume is less than h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
J of times pumped -n .
r/zany 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.
y portion of a cesspool or privy is within a Zone 1 of a public well.
El'�y
y portion of a cesspool or privy is within 50 feet of a private water supply well.
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.)
-�(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no ,
_ — the system is within 400 feet of a surface drinking water supply
e 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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or 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
1.5.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM -
NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 25 Rn ye.2a lday
Oe,6t yaan,3ta&Ze, azz.
Owner: Sue 7enn.e
Date of Inspection:
Check if the following have been done. You must indicate'Yes"or"no"as to each of the following:
Yes No
t 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 pan 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,e*cluding the SAS, located on site ?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
Z�he.. affles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes o
jExisting 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 I5.302(3)(b)j
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address?5 Anye2a Vay
OT3ZCL2n4 a e, CLbi3.
Owner:Sue 7ennz
Date of Insp77-9-703
ectlon:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):,6 Number of bedrooms(actual): �XJ�+ d p�
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: 2
Does residence have a garbage grinder(yes or no):ZGS
Is laundry on a separate sewage system 1yes or no):A6 (if yes separate inspection required)
Laundry system inspected(yes or no):YPj
Seasonal use: (yes or no): a I/ .the we2.P ha.6 not Been
Water meter readings, if available(last 2 years usage(gpd)): t ezt ed in the 12 m onth.6
Sump pump(yes or no):� It- .shou.Pd ge done at
Last date of occupancy: thin t.tme. See /2age.6
COMMERCIAL/INDUSTRIAL 64 & 6L3
Type of establishment: XA
Design flow(based on 310 CMR 15.203): dA gpd
Basis of design flow(seats/persons/sgR,etc.):
Grease trap present(yes or no):A49
Industrial waste holding tank present(yes or no): 41A
Non-sanitary waste discharged to the Title S system(yes or no):eA )
Water meter readings, if available: ,fJi4
Last date of occupancy/use: AM
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: il.&1& /9d191.jR,�i1g
Was system pumped as part of the inspection(yes or no):_
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
:?Septic
OF SYSTEM
tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
QUO Privy
d 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)
!LI)Tight tank _Attach a copy of the DEP approval
Other(describe):
Appr ximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Rn ye.Pa Ua y
(dent Baanztag-e , Ma,3,6.
Owner: ue 7e1/Y/U3
Date of Inspection:
BUILDING SEWER(locate on site plan)
it
Depth below grade:
Materials of construction: krOcast iron Z40 PVC mother(explain): tA
Distance from private water supply well or suction line:*#'t
Comments(on condition of joints, venting,evidence of leakage,etc.): The z y.s t em .iz
o.in
vented th2o yh .the houze ventz.
SEPTIC TANK: (locate on site plan) /er
�N
Depth below grade:
Material of construction: ✓concrete metal fiberglass.1D polyethylene
,k�Qother(explain) A)R
If tank is metal list age:d,�2 is age confirmed by a Certificate of Compliance(yes or no):.VA(attach a copy of
certificate)' 7��1
Dimensions: /!�6�( s�� f121 � //
Sludge depth: k U
Distance from top of nudge to bottom of outlet tee or baffle:
Scum thickness: 6 yy
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 9
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakag�e,etc.): Inlet 9
� e ,t .,Sltym i/, nori��innrl l um/2 the .tank eveay 2-3 t/ea2.s.
outlet to 7/ze tank cz zt2uc u
a owz no ev.e ence o ieakaye. Liquid ievei at the outlet invelLt
.c.a 51" l.
GREASE TRAHLt�A(locate on site plan)
Depth below grader Material of construction:l�oconcretc&—metall�r�fiberglas �
ofy ethy lened�9 other
(explain): IV4
Dimensions: XJ14
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle: r9
Distance from bottom of scum to bottom of outlet tee or baffle: .U/p
Date of last pumping: AA—
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 25 Rngeia lJay
77 e 77f 5 a2n a e, Na.s.a.
Owner.Sue Tenn i
Date of Inspection: 719103
TIGHT or HOLDING TANK4&&(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:_.AA
Material of construction: concrete metal ,fiberglass polyethylene M other(explain):
Dimensions: AM
Capacity: allons
Design Flow: VA gallons/day
Alarm present(yes or no).
Alarm level:_4�L Alarm in working order(yes or no):.&
Date of last pumping:AUyQ
Comments(condition of alarm and float switches,etc.):
7.iclht o2 o ding 7anTz a2e no /?,cezen .
DISTRIBUTION BOX: ZCf present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Diz.t2.igu.t.ion &ox ha.3 two .Pa%ea.a.Pa. 7he2e .ih evidence o/ zoi.id.6
cdaau oven, No evidence o ea age zn o oa out o .
PUMP CHAMBER&1l. (locate on site plan)
Pumps in working order(yes or no): AM
Alarms in working order(yes or no):_dZ2
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
IPum12 eham9en .ins not paeeen .
8
Page 9 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress:25 Anye.Pa Clay
e.3 a2n.6 a e, azz.
Owner: Sue Tenn.e
Date of Inspection: 719103
SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required)
2- 1000 ga.P.Pon 122caht .Peach.in.g R.i.ts. Both aae .in hydltau.P.ic
/a.i.Puae.
If SAS not located explain why:
Located: See page 10
Type
l` leaching pits, number:
4,?Q leaching chambers,number: Q
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensions:
/ISO overflow cesspool, number: Q
innovative/altemative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy .sand to c.Payto medium , ine .sand. Both .Peach.ing pi.tz ate .in
hUd2au.P.ic la.i.Puae, So.iiz ate damp waste watea .ins agove .inve/zt I?il2
o� the 12.i.t s. Vegetation .ins noamai,
CESSPOOL$(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: Q
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
-a.4
PRIVY locate on site plan)
Materials of construction: �i'9
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
/0,2 14 w nn nnoAonf
9
Page 10 of))
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properry Address;25 Rngeia Qa
I e,3
Owner; Sae Tenni
Date or inspect 9 0
SKETCH OF SEWACE DISPOSAL SYSTEM
Provide a sketch or the sewage disposal system including tics to at least two permanent rererence landmarks or
bcnchmuks. Locate all wells within 100 feet. Locate where publlc,vater supply enters the building.
t
10
Page I I of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:25 4nge.2a b)ay
Ue.6t 13a1tnzta9Ze, Ra-3.6. 02668
Owaer.Sue 7enn.c
Date of Inspection: 7/9/03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
/ t
Estimated depth to ground water b feet
Please indicate(check)all methods used to determine the high ground water elevation:
9Jbtained from system design plans on record-If checked date of design 719103
Y gn P gn Plan reviewed:
q�S Observed site(abutting property/observation hole within ISO feet of SAS)
yLS Checked with local Board of Healh-explain: A-s gu-..Pt,
l4LL Checked with local excavators, installers-(attach documentation)
qLs-Accessed USGS database-explain:.hLI n: .town. s a.atagie. n2a. u.3.
You must describe how you establishes the high ground water elevation:
d.3ed: Gahltetu & N-i-e.te2 Modei. 12116194 G2ound wa#.ert e2eva.t.ionz agove Sea ievei.
dzed: 11SGs - ORAPIzar,11on wegi daia �une 1992
d,3ed: USq, - 7onhnirn0 O1/QQOfin_ 9 ?-000- 1 LfrzL e #2 Annurjf /1 rz n qP-6 Q gaound wat.e2
1�
a
Leaching
Pits j 1r :eet
y7
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the bonom
of the leaching pit and the adjusted groundwater table is
feet.
Il '
•nrnr.•—n•r�*—r.— .nranr•nlw.s-.rts�.rrrran:T+tfe►t.1Rw+r..v ne+A�i++l7n�rt wit+ rR-rrr-T:1r---'.... ,—
TOWN OF /3a2rz�s t a&Pe WARD OF HEALTH
0 SUI)SURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION 1
^•T^1•�•••••.—.•.11�^.�TTt.Tt11.1'If.1T1 TR.R�t/lR'11T:r•t't�'I VRf\71T�^T�►1R�it�f7 �
-TYPO OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 25 Angeia Clay Qezt Ba/znztagie t'a,6.6.
ASSESSORS MAP , BLOCK AND PARCEL
OWNER' s NAME Sae 7enni •
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J P Macomber & Son Inc7111
COMPANY ADDRESSBox 66 Centerville Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
-
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
• 11 % ��1l1�
Check ohe :
System PASSED ,
The inspection i+hich I have conducted has not found any information
which indicates that the system fails to adequately protect public
he•alLh or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
.J
+' System FAILED*
The inspection which I have con tcted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
C1ITERIA of this inspection form .
Inspector Signature Date "d
ne copy of this certification must be provided to the OWNER, the BUYER
( Where applioable ) and the BOARD OF HEAL1')I.
* If the inspection FAILED, the owner or"" paradtor shall u
pgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 3.10 CFJR 15 . 306 .
partd .doc
1331 0 llt
ba c.(c
vow
25 Angeia Day r
• Oust Ba2rz,3taPUe, Ma.6,3.
[Je�� wate2
SEWAGE INSPECTION INSTRUCTIONS
I . Dig up system,
2. What kind of pipe?
3. How deep are the covers?/A
4 , How deep down Is the pipe?
5. Show water line on diagram,
b. Show now far away leaching area Is from water line,
?. How old Is house?
5. How many bedrooms?
9. is there a garbage disposal? A-O
18. How many people Ilue In house?
I I . Is house seasonal or year round?
! 2. Check pumping history at plant,
1 3. If needed get engineers drawn or as built,
1 a . is there a sprinkler system present? �S
1 5. If near wetlands measure distance from there to leaching area.
1 5. I1 system Is near water table, Dig test hole near leaching area,
At least 5ft below leaching area,
1 7. I1 system needs pumping let us or owner know,
! 8. Sump pump Test If applicable,
19. Laundry es no
28. Size of Tank. A S0 0
21 . Size of cesspools,
22. Size of Pits, f "— /• Q0a GAG
23. 0epth to water on all types of systems below inuer•t.
a
r
. t
:1pJRf1N�At SFWAQG OWPOGALCl'S' "MkEDTIDN MM
sysim frO1M IM icaoanwoo
,,�A a1,S�/•%�tg E�A wt�
Q-rna►: A a•-
OCifl AMoIMI'�+ifvslM 1tlwtau; � t+ot is ,lacatlon aav 1bs s�oproMirr as ,w„NMrwN►.„,.dwft
tloeas an�plan.N
u apt looaa4•asowe., ......._...._-_ ._ ._�._._.
iveM laaefrlt*yl1s.teanba:�
woo"allalwss►s. .__..
t000hfne pior". '.....
Nsaahino foolodws,
loa""q fordo,ewnwm.44not+rk�ns:.. —
ovwf w.w+sqool.
Nano of Tad+iwl ev: .
C" iaq+n,taad of p 4an seif.canlslor►01 vpetsR)an. 1
(euto so"Ow of s0{.$)O�+s of hyM I N%-If —. Nil
Fioafas aR loco pbnl
NumbM ens aolrlrN►atlon,._
'40th•1e0 01
doplh of scan MSA►% - -
lMotsrh�a of conotlN %*n;_..,+r.+..�...+
lmN:atlon of poun4wota:�
) ++_..,�... _
AGW toeaspaal e�ast be Pmw*.� of inspoetion).+._,_
cannn..nte:
Irate tah4aan of top, rdrauifa faMws.�ava1 of lrrn4if►p,Dona' of w�oeNiprt. sea.)
04c#"on silo plrM!.
fwo&n46 of
Dow%of sdwo.
C4WM Meo:
lnaRw eond+4am a soil,&ism of h auMa s1NJ►a.level of pow.conditiono/valpstasion,oft.)
�y 7 v
_`' COMNILYNWEA:LsTH OF !�UtISSAV"HUSET S �' ��°Fe�s ?000 ��
�:a.EC TNF, Or`�'IC' OF F.��L'IRONMEN'TAL AFF'�i��,
12,
DEPARTMENT 01F ENvn l'MW..NTAI, �C?TECTION
��. O1r.F.,V61N ME STRUT. A(lS-M% -.4(A i.qiqi+ ,GI 292•55+1+i
qra•+rarer
kk(; :f) PAIL C.Y.:LU.'C 't
ciV@*URFAC!UWAfpfE DOPOSAI•YS'i'TM ahSPEGTMfIE FQNM 1: :+amus,;,acnr
PART A
CERTWWATIM
f4ap.etr Aelia.e; r�S 14241e, LAX Matra ed o.n,.r. kUC-
e �"n sF��Y A ht a in NoWN....__... . . 01 a-61 W _....
s17fo _ ---
Ones w Mi•P•� � a
Now el awpec,�.r:tPai...f4tnRl .r
1 m a:i[1dFT- 67
straIM 1r��loetor psfaaaant to 964W of ifus S 1310 cm I6.00Oi
t.aefrattfMaaie: ✓ar -" '>Ot eQ.11hdk*A4Uaae_ .�ca .$S'�.... '? .......�!. ..t:3 O'1�SS
SHnUcAJ, STwT ua�T
'. ear;Vtr shot i have parsonsky irwpecrmd :he sawass disposal systaro at this addr"s M+d that the inhwMation reported below is 17U.4, n;aur.str
and eviffl iete as of the Lima or insoectia+ The inspsation was performed based'n znv lraihinp and experience In the prapeK 1UP211 M atd
mwvtda ce of arosfa sewave dissosai •velems. TAe syst&rn:
Pass"
CcMdl40nWV PWNe
Needs Further EEialua lon By the Local llpprorfns Autiwrily
Fails I
kalrasl�oe'a raavr+: �, Dw1: :... ...���0
The$ester++Mapo0lor shall eUbmit a COP,-of this dfwpeotian report to the Appraang Awhortty tbaard of,Health w OtplWivoin jNny t'y l}deys of
sot M'"Inq two b"aloct Eft. ff the evttan�is a shored avetem of has a dasdpn flaw of 10,000 ppd at praetor,the inspeatar anct ti a ws un:7wfatr
shas submit the report to the eppreposts regional 0&*of tree Depertrnwit of Er.•i,Ma•zrtwntal Peso. cdon The ori&W ov>w i 0e+�W.f s the
ayiFarn owner Ar14 G0l1if!s MOM to the bu^;:er,if appikeble, and tly spptavinp a.A%w0,#
Wn-E3 AND COMMENTS
. . i
I
SUBSURFACE 6EWAUE SAL SYSTEM MKCTX)w row
IPARI A
CBtl*ICA IVO jeen0sawA
Pl=0
Dino of laimpocom,
INVIVOCTM SUMIS"y'. CA 0 A. At C. aw 0.
A. SYSTW pAmm.-
I have rm f"v4 soy infonnal ion%vNA indicates lhat any of the fallula CAMAtions described in 310 CMA f 5.303 Ovul, *%w faiiiu
orbeft cWt Ovidus"d We*41*tad Wow,
................................. .......... ...
................ .............................................................................
S. SySn"Cx)"Ofncws^LLY PASS;9,
One or nWt*SYSIWn MVWWOI:nt*at 00SCribad in the "C"A"OhOl POU" 104406M no"10 be replaced or repaired. !'Nro
cairWO064"of the 1449scomarr of PePailf,as approved by the Board of Health, will pass-
infOcotf yes. no. or not datermined(V, i4.of IND). Describe basis of dinsFigiiiinatign in ap insftncqs. 'not rv. t.
Tilt w*Ot'c tw*is Al",unils"tft Owndl Ot OPW*tW has Qwrovided the sys inspactot with a copy of a 41:Ojjj..*ft Df
Co"Wisn"'(41"i0b"di"Oillitiftg that 4110 tw*Was inaWted within tw (20)Vast$Prior to the deft of iho,il isil:q,64ft,n-. 31.
the Wtic lank,-wholhor w not"tall, Is creftird,attuctmrso,v!Una .Show&substmidlil Wdiiiiv000n or cSfArlitIC I.-at;tat-A
failufa,Is Imiliftent. The systm*jN pass impaction i.I the a &Wic t4knil is rOPWied With a complying sopo jW'4 6:0
approved by the Saud of Hoeft
o" "am'="coia d ,
sivid,�a L,. iihs
with w (20)"a iie tenik is
SSwa�tr backup or t rasftattt or high slats 1"Or tovell 0666madinthe distribution box 6 due to broken or olimruI4 ad jjpjj%,,
�b
w due tit at brolli stftd at ww~� tAbutleft box. The"Voter"wits 011114 inspection if twith approval of ghi.11 wit of
faroken are resilsetd
arm is removed
W Wed"m m
tson box 1#4veNed or"**god
The Ovotsm►egtl 'C:Pkit"O"S Wier*thil")foul ti"A a your d4ft*0 broken or Obstrwetooll piggiii!, Tl,.o aystern
1116000106n 44 th OIWOVIO Of Isle Board of Hoeft):
k*ken pipets!are raPilecod
4!tt/rtetiion la lar"Ovoo
4
f
SkASUMACF SEwACW Dy►R)M WfSTEM WSPPECTIDN FORM
PART'A
C401TWICATMIN fouiwom e
s-eF01 �s A�g.�ra. "`r
(M-W �o J c
c1AIr at weepaaue.s- S/7��U
C. F4lRnGR EVALtJATWO hoi'REOI,I01W Sr THE DDARD GF WALt'11:
ConcMiono obis:whioh ragw1ro further sysivatien by the Board of Hefft in order to ve - t! 4 system Is fekinp to po'tact,sM
pL"e haatth.safety and ohs 0"Vironenant.
11 $YgTVA WLL.PAU MO 20#"QF"FAUN CM#Wf W IN,. wfftf 310 CMR 16.30311011'I1iV 1' IV*svirl,11M
a foot i"iJNGT7OMMa IN A MAWWR I NCH Mu PROTICT TAE F1 Iff ALTM AND SAFETY AND TM (f4Iti111{T:
C/asp001 er prigw it, *4NM 60 feet of wrfat it water
CssspxM m OFIvy try wiRhin 80 feet-if a bordoriny rated watland err a sah marsh.
71 SYNTM WILL FAIL dlflf.Jrtfi IM MD
OF iii'AID PLMX 'WATM ISUPPILM,If ANY)OFMWRAS TNA'ir 1-11k 8y>tl rEla ic6
FUNCTIMMI l fell A MAMINFfl T PROTUTD 711M fs AUX 11FALT14 AND SAFM ACID THE 111A11 ;
T'he system h"a .tic talk and soil abaofptiost avetem.. !&M end the$AS is within 100 cast of a surfft a wtr r erup�py, �tributary,
to a su a water auprpiy,
14W system R a*gait tank WW 004 Obsos;Rtion aYatarn aril the SAS is w?thin a Zww i of a pubko water s4eimly wah Tgo syttsrn as a a I'tia rant and SON tttNotption sYaatn and the SAS is within 60 fast®f*privets wars,supFsy,rep TI sy hoa a 1 eptic 'at*and soli abawrpfiort system AM this SAS is lass than 100 feat Mut So resit or Inel-s Mtn I.
private star suppilif NsU,unioso a wolf wow anslysis fer C'Morm bacteria A"Vale"ample eowgw wwh:Inaoa rfas the c pas
wait i roe drone pQd Usedtion from that fa a di am 'lets prasanea or arm""t"ultroysn and nitrate nitrepen is wins;t .a hNs
char palm, 1Natewdused to datamtMe distance_.... ��4WMianknasion not vtldl,
3i OT►IER
J
.I af'11
SUSSUWACts SE-WAGE 0QPftAL SYST M 9MS WTWN FOAM
PART A
Cf.01T1PIC,ATfaA1M tettrtMtttrarA
t�aea at sns'aettan�S��,O
M SVGT18M t►ILS:
you must irAkets elther"Yes"et'M3., to oecfh of the owiawlnp.
.�._.._ r have determined tftat one 06 Mors of the felloweng failure Candiuons.exist saribsd ih 310 CMN Is,203, The"%4, t tr rest
dowft*rkart oo Id identified bmkw. 7 he Sowd of t4aalth should be carve daterrnlna what will be necoaaary to aarrori, *%I.taiNr•.r.
1'es so
_ Sackup of seivet$a into facility W system component to on ovsdose"oa cbged SAS of cesspool.
019cherge or pcndistq of effluent to the.surface tM iproo"or surface waists due to en ovookmided or oirj{Mfs4i W;w
ceespoo.
SIOUC Ifobrid isysl i the distribution b above outlet invert dus to On Overloaded or clogged SAS or eosslMeed,
_... Liquid depth in tes.rpool is ease 6" bokm Invert or evallab a valurne is tars than f i2 char flow.
Roqulrad lowr+p ng roars 4 times in the last n t
Number of tirnas airs to
�a or obstructed pipats>.
gum
/Any portion of the, nil Absorption Systerh, ceesp"or prevl ee below the high OrVAWwa�r eievati ",
MV2AILat'
rttun a Ctsdipod or mrivv is wither 100 feet of a surface stater suaolyurt►ibutary to a aswfaoe naacer ray ,ply.
r of a to st:peel or privy rm witwn a zom I of a uui*4•von.
rtion of s es tava,al or privy it;wttN,t ofeetofoprivatewatersuitplywrtlQn*f a se"peoio►privyis issa-than 100 feet but'greats'thus 60%*Ifrom aprivetswear O►MY s'rel withbMe water q,eaaity*"&'yeas• Ifthewell has boon enal'oed to be aca�eptabla attach COPY of ward wttm rrro VIele tar bacteria, widetjo,orSPVC Ponilpoundn.arra mnis nits-p3 -end nbtrsrte8? /
Vcu rrwet odtee'ta 00hev "Yea''Or 'No. to a". of the•Wlowingt:
The'oNowing criteria apply to 5arga systorns in add* to the vriteris above:
The systern serve,e 0 facility Voth a deeign M 10 004 SO a greeter SLerge System)and the syselim is a a
hearth enrf sofmv end the e,nv ira�=tirnsnt use orpr at Mme of the following eondltions exist: ipniflsaa�R rhi tat R++Pub k
Vs.t so
,. Ow system is within 00 toot of a surface dt*i"Wow au;lply
_ the system is his Soo feet of a trtbutery to a Surface,drinking wrier supply
_ we,eyes y all) Ir<a(tk►crgsrt aenOttive was(kKeHrn WrAMs6 PrOlIftban Area- IWpA;or a titan");tan it ,, a 6�ubiic
weft+ pply waltl
T•t t•vrnm or oiler of tilt such systrsm&hall upgrade the Oystent ye eceo'ch" s with 310 CMIt 15,304{2,ofrrae of flit papa _ er!t Mr 111rtlter Irefev*statfon, a+lasera sonetd the;�iI re51io;tM
f�a,radiA
:!;UUU 1FACA UWAM OIMl01:AL SYf,104 M FECTM fa0ltfl/
04"T a
CHMLWT
rases art Mortrleoow- p
if 11►a following have hmen done;"ou nwat inlFCats eithar "Yos" or "No" as to each of W fuQowlnq:
Yes No
_ parnping iraarrwtivn was provided by Vie ownvi occupant, or Yard of Health.
_ None of the syatom+csmponents have boa►pumpW for at least two weeks and the system,has been rew,vklp r4!4'►AIl!1a++-
►at" dwing that poi large valumes of water have not boon mveducoo into the system recently or as punt•V',-is
ipar,ection,
As Cuiit plans have biota obtained and exa►nlr►ltd, Note If the}+we not avallabis wltb N/A
The foafty or pwsNln a woo Inspected for aagns of s*wasia boo;*-up
This system does noit r"vo non-sanitsfy or irsdtratrsal waste ftow..
Tow Oita W"tnapeota d fe►signs of brookew
Au tystsm cor►lpprtelcs, excluding the Rog Absorption;Ystom, have boon located on the sits.
T' The sOpbo tank Moroi-Am wets uncavoi ugnod,&W the inbprior of the septic iv* was inspsetari Iw c*n,fitt x► _'btif%ix
m tees, rnatarial of cot atruation, diR►eneltals,depth of liquid, depth of sludge.depth of scum.
The sit*and tocetign sf the toil Abowptioun System an thta shro haw beets daterrrdned based on:
f/ Euietina iptwai o". I:or*xampia, plan at S..O.M.
Daterminod in the held fit anY 01 the}Mlute oritoris related to Poll C is a1 Istuo approximation of Mmnce O I:aw:LCt: Val:�sw;
T' 1}6.�a2f9rte3.
The haility owrlor halm occupants,if dwitt*M trams owueri war*prodded with information aw the proper mointono,x e of
SrrbSurfece Ci�apaatd Fvettrlrsa
SUMUMACIE SEWAGE tVSPMAL Xy:rrLW tl PEt:l'btM FORM
PART C
t SVSTEltfl PRO Rwi rum
O"Now,i ��d , w �fQr�� VAC
finr.ri.= a v f�,
laws at' Sr>Ica
FLOW Cfalf)QIIXAM
ORMORM&L
Onsion flow. /10 ._p.d A wdr°�^.
fi►umber of b*droortft 1*alatil ..!�!`,,, Vj"*w of bedroornc(Dcbool)�..
��s4s6 DB>;fOf1111aw„�........... .
*Fwtdaa► dy
of Ear►ant r*sieka+ts
t}srt►s4*prfndt.(yea a rwl: �s .c,�,
Ltneo)dry lt*WMO OVOWrt) I'fet at tro;: If yoc oapora.o inspection squired
Lrwrm*r sylterp lnspsctod- {fie of no) S
8a*ssnal woo,lves or rtol:.,,.,_.,.
Wkner motor mad ngs,If evg1l able llost two vasr's wage(gpdi:
g,..r,w PORV I"M or no},
cast date of oowtpanrY:,(�`g��f- '
{bisl4rt ttowr _„�,_�P4• I>losed on 14.203"
Ik*q or dotir flow _........
04-040t*trap[,r*afbrtt; (vat of na),r....
fn•ont+ial waste tfoftlMe4 Tank praesitt: ids na;•_.......
fYs>n•nantts+v wools d)ocharged to"a? &lVatarrb: (Yes or wo;,,•_,
Watot rtaettm
Laot-date of oseuponcy+.....
d311Q7R:IDeecriba! _..�.... .. .. �.� �., ._ ..�......
'.etr dot4 of OcC T',........._,_
Atr #tA!1911tDRRlI/►71o1i6
PdOP"! aitd Drop f inf:rlfrat c s. 1�"(.
Sysfe+n pumpod st port*f innf artioss (yet or
If web,v*karne
R"Nottfbf ptaffTpiR4: �.__.____...._...._...... ..._...................
._
._, 9� Rift tankaAia> iers h�ae.'s4ei:tabatospsien tYwtarrt
. •.T_ flipbg6a cesopool
».M pwwrlowr Cesspool
fbivy
Owed tirstam IV"*r sw) fit"08. attach asavieast inapoctk*r raaoNda,if aryl
!'A fothrmia"ate,Aftach ca.6,v of up f*dote operation and meintormnoo Gantract
_,..__... tight la<+k Capv ae 4:TEr Ap4rov*I
apt*, .,.._.._ ._ ._....�...........__._...:._._.._�._..._.....,..,
A!'* WWAAn AGE of aN o*enpanentM, t*a OwWed lit Mnownl anal sours*at bnfprafrmafa7n; ,, /`
char"*$We doteeted when WINIng a!chs srW (yea at nol&d
SV§940W*M SWAM VOPOS"sYl">IM MlUPfCTION FORM
PART C,
SYSI 1004M MMTON tam ebstsdf
Ptw,&,Apr^ ArAq Q fq ((,r,
I MrW, r�
�bvg eat,
O'NO oo b+@Pw*m: Sl boa
(lnaats on peen!
N
Dtreth Wow orado:
m'"O OP of cawaVuame"!,_•„cast:roe_,f 40 PVC other tsaptsio)
-.._..........
... ....-
OLlto-oo ItxAtr.t.vs.w 8tr9p1Y W4014 or suotian Nrta
t�ialr►Irwf
CrrP9NnsrNa:iceewlitlnr�eel jOlrftA, venth,�{, widattffe of iedreSe.Pate?
�...__ _.. _..........__..M ...,..., ....--- —�,... ..�_....._..,_......_,,..
wrete T�c.y
ilo•:ota O+►arts OW
n
049th befow weft;.
MmterAM of construotfen:,roam ett_••rust —Ftbetviess . PcOyethylorw _ia4harts><plAin,
Ff+lenk+A Notol,Nat a" is 0"ao wooed by Cwtl:ieete of CottKtlirnao_». (yes.'No?
Obfteslow G Gisi_—..---......_.......,.....,...�
Sh4ge,depth; n
ft-Urees IItemtop 45*do*to bomm a.: wAst tee at tAtftl•e.50
Owterme!rom too of seam to top of owttat taa or baftla:_Q ,r
WatPretae Nato b4av 41 of acorn to botte•r at ewfet to or twfflo: /s
4aw d mwwone••ere dowfarlrtsd:,q�.,,,,����
Comments:
trtfeofnn,a•tdetief<t for pumping,a ,n or►d a►tht test or po}Ples. dyjtln of A in r ar on tc v►7vor�t �at�v►a�CtfpPt I;Kogrtr.
17
svidena of Woke".ate. �r ,C a S � cX 0. � .�Sl•?e��.�..T�:
Pieerets on site plan) 9
i
Aia'stf below proem:,,,_,_
Motomal M canstwation:__•_eoncrets c."IM.,, Fiberolsu MMylarro,,,_,nttw(e&oWn)
>mim t1liSacllaM:
f9ie taeece AAPea top o4 Dover tG tals of oWkeI We
ON tanos troll bottom of SOWO to boom w "a Or be"*;
Dole Kt Aaet/KM7tpMIQ:.___...
C.OrPMUerrts:
ss:ronwttarlelmtieff for t►ttmpb cclrdolw of lNet and outw tone or bOMb4.al"I'of Mquld ieevei Me raleeon to Quest Invert,atrr.roa,et'art il:tayrtty.
swilarers of woke",am
SUQtSUOIFACIL SEWAGE ILASPO;AI&V'1.1EM MSFOICTI I FORM
MART C;
SVSTRM MFOP MATW"feesrtttiWWA
Heapar+r A�Msae: m?.r }�t
Orrre+: e,L�a V pQ 1
tans ee'k�w: S/'[7(00
TIUW OR HOkOM TM01l: . U e,,oc oust be pumped slat 10. of M time a'f, kupoctlanl
: PWO on she ptent
Dow:brow grsals:___._
Mg.twial Ot titMetrioatuan; �Connrete _..IRetel oetptaos....,is yeehl°oene_,f►tt+et+,rxtals:n�
Damon ftow: ►Te11on+140,0
Alarm:wesenr
Alarrr tows: Aki<trat ir+w kpig nraNf:'ree...... No..
Ditto at prsralteus pu n*v!
Cnmrr�eaett
io::,rddf pv r)?irgot 9"c unrrd# of slerm Anal float switches,etr,f
DISTIOW- 1111 @ aat:_D(
Ela:ate on site plan)
Dihr'! of go"►evef above MMOI event:, dv
Ccavtrrents:
;rote#f i tw bred distr-11%44pr►is otxrarl. Bodenj.A of aioli psrryarret wnee ral ;04''1 insa,e cut ct box, artc.?_
__..�..re,._...'��- 6 e�_,,,,y�+ s L.a.c�-Q-��....,��cJ.:.-.1`'�:..4�.�.'�...�_.�1....._�Cl,�p,...••.�a,.a.�ua►.._Q��..�:� �r,�
...
«_«w,, �,............,._
KOW CHAIN"
flocete pT sits piety,
tins in waking order:(Yes or Aia..,._...,..
Abren,s in work"order iYss or
4crtPtent;:
Innfe enndltio o of purnp chambet,c OVA of pumps and Opmou onatnees slr'!
SIA L SIMFACE SEWAGO Cape*"GYf1'W msprgcTw"FORIA
PAST c
.....ty w alf/��gt�q
cyfunw: A C- a..`
Oslet hwre60'
OWL AMQINOW SYSTtM{ta"kz
(Mcsta cwt erte mm,i1*memo;excovesii)r not requir*d,IDC*don may bs assvaMmeted by ntm--404somve nWthodsi
It not I4Osted.e+c~
oft,rllafbsr;...pf.,...........�,_.,.,....,..,...........,.,.......,......__._,..,,.4..�.. ..._..__...._......,.,_..,...
lsee"gawai".fOAPRbar;..r.
lesrcl+ind trwrioss,twnibas,fen�rh:
iseolf+np Aqw ,nu"N"I, 4knen►hans:,» __��—__
avernsw. cosspoel,
Aftsrtwtive eystes":
Neff of Techr%0440
C.IAWVPOwtt
i,k.ss eanditivt of oo�.slgns of hydrsgpc isriu►a,Ioeet al pondlnd carr4slon of vpstattan c,l
i.
A sa ..� - Ss .li.��' ._, mac .
t:oo tts on oft*pent
'�epah te®M Mould Se inlet
fapth of sea"Isya:
uop+th of team lays►; _. .._._..
tndi::et!an of yroundwsaar:,,,,^,,,,��
initery losorpaal+naiat be pl►�nPAa ao rt of inspoerienl .......r..._...._........_. ..,,.,,.,_�.�....�......._. _,...._........._
Co�sonsrRe;
inato 4wm*aw of•*M,sir" ydraulie lsiiuit, level of pan&*,candt' of vetletNion, sic.}
PIBIMtl;__..
Ow-ats an silo PWW
Ohm"als of eonstnieeoo•.,..1_-_.._. . `_,,,_ ,"Obmrrtsio�tt: �
Dow*of SGW4;
Gowy'nonts;
Ir+evr ewwKtiar:o'soil.sign of 04 awk alum, bvel of pondins,cwld t"of Yopetatien, etc.i
'RMURFACE WWA06 OWPOSA4 ST STIM 00ffCT ON A•ORM
PART t
elf L
dm,04 h 1-0 ram= S l �o O
^cam of WWAOW OtsPo$AL sr**MM:
tetctuoa ties 10 at Nast tvv*OWO%on#w rstaretwo!oold"larka at b"Chmoriks
ior.vv so woo w man ';)0' !4nc It*whoa oublu:water►apply Contss 011:6 hQUAO)
` b
�-e CL i
98
J
I U"URFACI SEWAGE=SPG"L SYNTON WSPECTM NXIIII
PART C
ftepottAdIfte— tf,%7 4e
Owen fq ax V av\
04"of
............. ........................................ ................................. ..............................
%,!Pd Type_ .................................................................... .................
140$101ind-Otow. ........
.1; Oaks webmte visited
Ot-sorwhe,r. Woos 044-bod
"Ifewwwat"Slopth: Shoo*
SITE DAM slope
rwirim's water
Chock co"Of
Shallow wrom
fifflira*Wd 040th to F0,11
poo<;o"Calq,sit the mottiatU used to dinormine High firoundwater Flavotion:
:rbtairtad flan DesiSlo Plans on tov ord
ObsFeave#1 II.Ile AbLft"S PrOP00W. 4A swvm%IOM hOlt,bOSIOrnent sump etc)
local coom1pons
Chocked with lacoi hard of 1140th
Chocked FIEMA Msps
MoHkod pWrWi,410 Words
choollod local*%tovolaws, 44tMoorl,
(,-"d VSGS Dote
h"4" YOU 061040ifthOd tic VAintiV-6101 FIGVNIIOR 1pim be Completed
O.Q�,e ry—S 4
rago 11 of$A
Oct 0714 09:21 p p.18
Commonwealth of Massachusetts
�i Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name
information is 'West Barnstable MA 02668 10-7-14
required for every
page. CitylTown 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 and of the form.
Importarrt:WhenFilling out forms A. General Information
on the computer, \``�� ..............
Z.... r'.8S
use only the tab 1 Inspector: ��:.• -••..., •may'/
key to move your =O N$
JAMES
cursor-do not James D.Sears =0: rn
use the return = •-�—
key. Name of Inspector
Ca ewideEnterprises LLC
Company Name uSPt�G ` -
153 Commercial Street
Company Address
M - _
ashpee MA 02649
Cityrrown State Zip Code
508477-8877 S1623
Telephone Number License Number
B. Certification
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
qa���dpt 10-7-14
afispector'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.
110 I�
15ins-311S Tole 5 Offidal Inspedl F :Subsurface Sewage DisPcsal System•Page 1 of 17
Oct 0714 09:21 p p.19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
25 Angela Way
kluj-"
Property Address
Jeff Prescott
Owner Owner's Name
information is required for every West Barnstable MA 02668 10-7-14
page. Cityl-rown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Pass system. The system is a 1500 Gal.Tank D Box and three 500 Gal. Chambers.
13) 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):
tS;ns•3113 rdle 5 Official Inspeclim Form:Subsurfaw Sewage Disposal System.Page 2 of 17
Oct 0714 09:21 p p.20
Commonwealth of Massachusetts
gum Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name ,
information is required for every West Barnstable MA 02668 10-7-14
page. CitylTovrn State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpslalarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health).
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins M 3 Tille 5 dflidal Insrection Form:Subaurface Sewage Disposal System-Page 3 of'7
r
Oct 0714 09:22p p.21
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Angela Way
Property Address _
Jeff Prescott
Owner Owner's Name
information is
wired for e� West Barnstable _ _
� every MA 02668 10 7 14
page. Cltylrown State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any) .
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance: _
RR
This system passes if the well water analysis, performed at a DEP certified laboratory, for fe
cal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in vowipM is less than 6" below invert or available volume is less
than %day flow.4 kA/li.,,
Sins-3lt3 Title 5 Officid Inspection Fornt Subsurface Sewage Disposal Syslern•Page 4 or 17,
Oct 0714 09:22p p.22
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name
Information is
required for every West Barnstable MA _ -14
page. 6i /Town 02668 1
State Zip Code Date
7 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. IThis
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal colfform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes'or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113
TRIe 6 official Inspection Form:Sutsurface Sewage Disposal 5yatsm•Page 5 of 17
Oct 0714 09:23p p.23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owners Name
information is Barnstable -
required for every est a stable MA 02668 10 7-14
page. CirylTown 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
Q ® Pumping information was provided by the owner, occupant, or Board of Health
Q ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal Flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back 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
15ins•3113 TitleS ORcial Inspection Form:Subsurface Sewage Disaosal System•Page 6 of 17
I
Oct 0714 09:24p p.24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name
information is
required for every West Barnstable MA 02668 10-7-14
page. Cityrrown Stale Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal. Tank D.Box and three 500 Gal. Chambers.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes 0 No
Water meter readings, if available (last 2 years usage(gpd)): well water
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: present
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft„ etc.)-.
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Dispwal System-Page 7 of 17
Oct 0714 09:24p p.25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name
information is
required for every West Barnstable MA 02668 10-7-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (corn.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: _
gallons i
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3113
Tide 5 Official Inspection Form Subsurface Sewage Disposal System-Page a of 17
Oct 0714 09:24p p.26
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
h
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name
information is required for every West Barnstable MA 02668 10-7-14
page. CityFown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2003 Premit 2003-521
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 46"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 3'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: 1500 Gal. Precast H-10
1
Sludge depth: ._--
t5ins-•3113 Title 5 Ofticiai inspeo.ion Form:Subsurface Sewage Disposal System•Page 9 of 17
Oct 0714 09:25p p.27
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Angela Way
Property Address - -
Jeff Prescott
Owner Owner's Name -�
information is required for every West Barnstable MA 02668 10-7-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29'
Scum thickness 0" - -----
Distance from top of scum to top of outlet tee or baffle 8..
8"
Distance from bottom of scum to bottom of outlet tee or baffle —
How were dimensions determined?
18"
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank at workink level. Tank and outlet cover at 3' below grade. Inlet cover at 4"out let
tee.No sign of leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ outer(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
15ins-&13
Title 5 Official Inspection Form:Su6surleee Sewage Disposal System•Page 10 Of 17
Oct 0714 09:25p p.28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owners Name
information
equire tifo a west Barnstable MA 02668 10-7-14
required for every
page. City/Town State Zip Code Dale of Inspection
D. System Information (cunt.)
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 ❑ outer(explain):
Dimensions:
Capacity: —
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order ❑ Yes ❑ No
Date of last um in :
p p g Date
Comments(condition of alarm and Float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins-3/13 Title 5 Official ins ect on Form:Subsurface Se
wage swage Disposal System•Page 1 f of 17
Oct 0714 09:25p p.29
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
owner Owner's Name
information is West Barnstable required for every MA 02668 10-7-14
page. C1tylrown 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.):
D box is 16"x 16"4 below grade w/cover at 15". Box is clean and solid w/two lines out No
sign of over loading or solid carry over.
I
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:
t5in9•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
4
Oct 0714 09:26p p.30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name —"-"
information is
required for every West Bamstable MA 02568 10-7-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number_ 3
❑ leaching galleries number:
❑ leaching trenches number, length:
Cl leaching fields number, dimensions:
❑ overflow cesspool number: —
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc"):
Leaching is three 500 Gal. Dry well Chambers. Chambers are F below grade. Camera out
both lines. No sign of over loading or holdind water.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Oificiai inspection Form:Subsurface Sewage oisposa;system.page 1a of 17
Oct 0714 09:26p p.31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name
information is
required for every West Barnstable MA 02668 10-7-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions _.
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113' Title 5 Mlal InspecWn Form:SUDSLOaCE Sew209 DISposat System•Page 14 d 17
Oct 0714 09:26p p.32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
25 Angela Way
Property Address
Jeff Prescott
Owner Owner's Name
information is required for every West Barnstable MA 02668 10-7-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
IL
/9 -9 = 73"
6 r7
q -3 = y40
r3-3
Ppoi-
c C
Cie-
4
T
p
3
Eck
° ° wAw
t5ins•W13 Title 6 Officiel Inspection Foore Suosurface Sewage Disposal System-page 15 of 17
Oct 0714 09:27p p.33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
25 Angela Way kiy
Property Address
Jeff Prescott
Owner Owner's Name
information is West Barnstable MA 02668 10-7-14
required for every
page_ Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells 10
Estimated depth t high ground water.
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed. 9-23-03
Date
❑ Observed site(abutting propertylobservation hole within 150 feet of SAS)
I
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 9-23-03,No G.W.at 13'-8". Bottom of chambers at 7'-6" below grade. Bottom of
chambers at 6'-2"above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3113 Us 5 Official Inspecf.on Form:Subsurface Sewage Disposal System-Page 15 of 17
Oct 0714 09:27p p.34
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
25 Angela Way
Property Address -
Jeff Prescott
Owner Owner's Name _
information is required for every West Barnstable MA 02668 10-7-14
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-3113 Title 5 Official ii ispection Form:Smsurfeee Sewage oisposel system•Page'7 of 17
TOWN OF BARNSTABLE
LOCATION ZS c-ptb k C SEWAGE
VILLAGE 74-Z
n,. ASSESSOR'S MAP & LOT
NSTALLER'S NAME & PHONE NO. )(30G
TIC TANK CAPACITY I�ab
LEACHING FACILITY:(type) 7r (size) ?TU
%O. OF BEDROOMS_PRIVATE WELL OR PUBLIC WATER-
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No —'. _
y4 p
Z- 50
No...............
THE COMMONWEALTH OF MASSACHUSETTS
93r2- BOAR® O. TH
AV.V...........0F.......B.. ZN... ..ff- .
Appliration for Disposal Works Tnmunrtion wrmit
Application is hereby made for a Permit to Construct ( Vf or Repair ( ) an Individual Sewage Disposal
Syst at: W.)23..ovs ;:zr
.
TT Location- dress or Lot o.
uGl...._./ ..._.. .. ilt„G�Q.l�rr �.4- - �N GG�� /U G ...............
s......-•-•----- --•-..•-- ............. ...........
ez Address
i ...............................................
Installer Address
Type of Building Size Lot_--_gt..77__',4.Sq. feet
U Dwelling—No.•of Bedrooms... Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
Q, Other fixtures -------------------------------- ••. .
Design Flow................w.5 ..._....._....._gallons per person per day. Total dail.,flow..._..... ¢d---------......._..__g�llons.
WSeptic Tank—Liquid'capacity�P.gallons Length/W.6..... Width,5.. .._.. Diameter................ Depth3 8.....
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........,-,---
____. Diameter..........i....... Depth below inlet.....4........... Total leaching area-4A/......sq. ft.
Z Other Distribution box (✓) Dosing_tank ( )
'-' Percolation Test Results Performed by..........................................................................�.�'�^'.....�t._..!.._�r.' -.. .... DateJvl c.30......I8.°
Test Pit No. 1......2-----minutes per inch Depth of Test Pit... Depth to ground water........................
GL, Test Pit No. 2.....A......minutes per inch Depth of Test Pit.---/3 Depth to ground water........................
R+ n -----..•. -----------•••---•-••----------------------------------------••-=••---..................................................................
O Description of Soil......... .:1. n__?aP..s??l Lr2�`'-.�io.aF1!!!E Map--S�4?!v--..Ga��'/.Sb�...�SrH��_!f?
x ._�AM,e:....C-X& e t.....---••-�. ----Q-- � �� �,�'s�l� so.c......1Q''.-..8¢...MEv....9.`.......•...........
01
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------•-----------...--------------------•------------------•-•---------•--•--...--------.....-----------------------...-----------------------------------------------------------••----
Agreement:
The undersigned agrees to install the aforedescri d Individual Sewage Disposal System in accordance with
the provisions of TITLI 5 of the State Sanitary Code The undersigned further a rees not to place the s stem in
operation until a Certificate of Compliance has bee ..is d by the boar f a h.
Signed................. .... ---- '' . ..........P--- ..
at
. - ..(.� ...
Application Approved By.... ate ........
Application Disapproved for the following reasons---------------------------------------------•-------------------------------------------------------......-----
............................••-•--•-•--•--•-----------•--------------------------._..........---•-------•-•-•-•---•-•-------•-•----------•-•----•••---•-•-••----••-•••-••-----•-------•------......_..._
Date
PermitNo.......... ----------- .......... Issued_.......................................................
Date
No......................
7 Fss........ ..._. _
9 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................u ✓..............OF.......:'"� .1. A/ _',T.ti.l.L f
Appliratiun for Disposal Murks Tonstrurt"inn rantit
Application is hereby made for a Permit to Construct ( s � or Repair ( ) an Individual Sewage Disposal
Systp at. S
--• ......
L.34
1L�t-io ........................
--� --'--- ......
-------/-1---i-✓- f =t" ...-1---1------ ..-�•---
....------_. --------------
or
fir f-),,,Ul41 L
...................... .................................... ..........-.....................................................................................
Address
Installer Address f
Type of Building Size Lot--------------------------Sq. feet
Dwelling—No. of Bedrooms.......... ..................... Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
13.4 Other fixtures -----------------------------••• -
W Design Flow................=_---.
.................. per person per day. Total daily flow.......... .__.._..__..._...._..gallons.
WSeptic Tank—Liquid capacity�`'..'1.gallons Length.Z?..�._... Width.._ _.... Diameter................ Depth._a.
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------------ Diameter__________ _______ Depth below inlet.....4. .`.._.._..... Total leachingarea. � �......sq. ft.
Z Other Distribution box ( Dosing tank ( )
Percolation-Test Results Performed by---v::.��. E_.'��..:':�..�_-*:'^! '............. Date:A:!''r_-_-J.'_. Ili-
.......••,�a Test Pit No. 1.......t_......minutes per inch Depth of Test Pit___,/-1_-f.__ Depth to ground water.....................
f=, Test Pit No. 2_...__=?._....minutes per inch Depth of Test Pit__..Z�__...._.. Depth to ground water........................
------------------------•---------------•-------------.------------------------------------....-•-•-----.-.-..................... •-•--------.-----
D Description of Soil ��---------=------=` ��-- _,.. i1 n
! r �-� r
!J !
W . /j_.vt�
U Nature of Repairs or Alterations—Answer when applicable-----------------------------•._._..........._......__.__..._..................._..............
Agreement:
The undersigned agrees to install the aforedescrit�d Individual Sewage Disposal System in accordance with
the provisions of TITIL- 5 of the State Sanitary Code t
The undersigned further a rees not to place the system in
operation until a Certificate of Compliance has bee• is >4 d by the board f 'ealth.
i
Signed-------------Cti 1..........
l��. '.......-•y= -� .. 11
_ .. .. itt
Application Approved BY v--------------------------------------- .......... -- ----
Date
Application Disapproved for the following reasons-------------------------------------•--------------------------•--------------..........--...-•--••........._.._
•....................................•-....--------•-----•----•--------------------•---....---.....-----•-••-••••-••-•--•-••-•-•-•••--••--••---...••---••••••-••--•-•••-•--•-••----•••......••---------
jj ----•-•-----..Date
PermitNo.._..---cC.�... .--•--=-•------------------- Issued_------••-------------------- --....-•---
Date i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF jHEALTH
.....� � ................OF......:!r`-�..!.'- S ............................
Trrtifirate of Tuntplitinrr
THIS I TO CERTIFY, That t eY_� Initlyial Sewage Disposal System constructed ( or Repaired ( )
!.� ram = -�� S
b ::.. ----------•....................•-•---------------------------------
........
-.............................
-.........
.. -------------------
�--- Installer
at....
has been installed in accordance with the provisions 5 o The State Sanitary Cod-- a des din the
application for Disposal Works Construction Permit No..__. .P._.._ .3 ...... dated___......-=1- � ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... ....................... Inspector................ ,
20..............................................
THE COMMONWEALTH OF MASSACHUSETTS
�-- BOARD OF--H. ALTH
N
� 2 ................��' I................OF.............._.. ........................�.--....r...�::Q.L:."......
No ... -- • FEE........................
Dispusal" urkii Tons tr ion prrutit
Permission is eby granted........�.-C� ?nC�.!...^�....�1 JC_.1...... .......................................................................
to Construe_ or Re ate' ( ) Indivi ual Seka!ej Dispgsal�S em
atNo......................................... ............. - "' -......-� ��-�.
ri Street
as shown on the application for Disposal Works Construction P._ermit-No:-�.•C�__:1- a d..... ............
_ ,. Board of Health
DATE.:::; --•-•---••--••--f..
FORM 125S HOBBS & ARR N. IN_C_., PUBLISHERS
y ) ..J
<Departr Tent of EnvlronmenZ? t Management/Division of Water Resources
• VWATER'-bN-FLU COMPLETION REPORT
f ti WELL LOCATION
Address l f'"►t � - , t.�a y
City/TownCtl '1A 1A2& VA(1:t 1"714 S 5 r
G.S.Quadrangle Mapes'""?' /� iff
Grid Location t
Owner A w I a y"
Address L J,->� � /'c/1( i t/(J l s�3ls�I'tt/1.r 4 E44L4i -.
i/WELL USE CONSOLIDATED WELL
Domestic❑ Public ❑ Industrial ❑
Type of Water-bearing Rock
Other
- Water-bearing Zones
Method Drilled 1) From To
���� e� r�� 2) From To
Date Drilled P 3) From To
4) From To
CASING
Length Depth to Bedrock
Q Diameter 4
Type '~ r-• UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surface Sand: fine❑ medium❑ coarse❑r
Date measured Gravel: fine❑ medium❑ coarse0
GRAVEL PACK WELL Screen: r f/ C�
Slot# length r from to
Yes ❑ No i
Split Screen(or 2nd screen)
WATER QUALITY TESTS MADE' Slot# length from to
Chemical ❑ Biological ❑- Depth To Bedrock .4111ff r
PUMP TEST
Drawdown feet after pumping days 0; hours at U GPM.
How measured Recovery feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
i}G`,1f JDRILLER ff�� Cb
Firm 1 t.1J V� ��y1 11 i C,
Address�,c
City ..:/ �"17 j�✓`�C+ ��//�
r / L ,
Registration NO.
Operator's Signature
Please print irm y
BOARD OF HEALTH COPY { 15M.2 84-176471
Great
W ECT/PEDS-TRANSF❑RME c 102.f� 99.85
' �< ��` ; ASSESSORS MAP:
PARCEL: 1� 1 00.33 TEST HOLE LOGS NOTES:
oX u\
s0 99.24 s❑IL EVALUATOR: i�1w,(l✓f� RS C5E
FLOOD ZONE: 000 Hf1'ZK L-0 1. VERTICAL DATUM:
�� WITNESS: SAM 4Vi¢ITE p.
��rz►1. �. N .
As R �� �� n4 Sr REFERENCE: �� � 1�� C 2. MUNICIPAL WATER l�7 X OT
••� 9.30 DATE: AVAILABLE.
3. SCHEDULE 40 PVC PIPE' T❑ BE USED THROUGHOUT SYSTEM UNLESS
ago (X� FrL ❑THERWISE NOTED,
� r PERCOLATION RATE: �RSIEVE �, LT�}i2=� 1 V
'K �'� C� l •\ 9811 C1.�55 I d l L,
4 s --3v 4. ALL PRECAST UNITS TO CONFORM WITH AASHT❑:
100.8 BASIN TH-2
0
r1 TH-1 EL 91 `f3 5. PIPIE PITCH - 1/4' PER FOOT UNLESS ❑THERWISE NOTED.
� PILL �•7(0
S�>Jdy �o�lH l01�4ly 6. ALL C❑NSTRUCTI❑N DETAILS TO BE IN CONFORMANCE WITH MA. ENVIR❑NMENTAL
LOCATION MAP •� V", ,2- CODE (TITLE V) AND LOCAL REGULATI❑NS.
�w ,C 96.29,,:::- 94.72 1; 7. CONTRACTOR TO VERIFY L❑CATI❑NS OF ALL UTILITIES PRI❑R TO C❑NSTRUCTI❑N.
S4
10q(� l �X/SnN� I.EA-cry- PIT SE F"i C- 1G it t
100 N 04 WELL.,
�� Py ��i�� �� � r F -_
9.5 W LL 9,84 CI LO Ajj ---
Lot 24B & 25 1i4 $1 3 SIEVE lo) �� R-L4, uN5UIT)► -8LS SoIv? S �pY�Ajl) Lt-l-y-clfl/IJ6, To EL-_$l_ 3---- -
99.2 4s,ss + S.F. �� (Dl att� 2"!l X �� Sknn,�t,£ _ LPL , tHv� �Z w CL��IJ G ��I/M S NO-
1.1 - AC. St�.�>7 �( a b +-_cam
CS co v' 3 93.20 77•?b ----- --
97.02 E T I C�'
Map
Y Y Par el 7 ECT/PEDS C Q- NO 6W 065e-zUra- D
98.49 9 SEPTIC SYSTEM DESIGN
� �
97.85 0 9 FLOW ESTIMATE
(S , 98 o - BEDROOMS AT 110 GAL/DAY/BEDROOM
97.0 �N ti a
SEPTIC TANK GAL/DAY
x. .tib Pa ved 88.82
Drive 9e x 98.32 /D /FND pp
x 96.40 GAL/DAY x 2 DAYS
} )SU ► 96.40 ati GAL
96.7 USE I+SD� GALLON SEPTIC TANK - NEl�
x 95 6
- SOIL ABS❑RPTI❑N SYSTEM
95 6 Garage
E-
x 3
5.96
( C�wry Prz�cn sr (,��c Cl a . S
-• #25 1
T17F=97.38 W�Z4 STUNP- l-N A-LL- ('33•S'1k131wx2r0)
(Assumed)
x 95.37
_ SIDE AREA: T(33.5)Z+��3�x�x2- x0,
x 94.31 Deck BOTTOM AREA: 33.S x f3 k 322,Z7
x 2IN-C ° AR 95.8
S . fit
9 5 . SEPTIC SYSTEM SECTI❑N >y� ,G t'.0
d,
' .
12IN- ED r 95.43 d D 5
x
�� 93.44 •�, `s`�'{'t dVi�-t;. 7U � Sl.�13 � � .3
T F2Z OL ? r 9-f
91.05-x 91. Ups 1� o D
1.94x 93.36 91.4
x 19IN-CE AR -CE R 1
89 5 �'B2� Cbve�S
.o 91.43 2 h ,�y- .ro �
�C. Q.U
. (T06 �x 91.18 r �� I�
90
90 0 9Z &FFtt �I��� n a
� Ci
ae r ate. ELEV 1� 1JE g3 8(0,50 Q Cl1 7 II v
z 88.69 x -.25 * � 3 �_ ELEV `� � s n� ease vd- D- X 7 �i
BO (�
S3, 1�E, A'5 ���0HOFVASS� l7 GAL 6b.� - LEV 3�4"-l'/ double
Vc.J7A 1Js - g TERRY ���� SEPTIC TANK EL WaSke Srne �� �y
8g �, W Y 0 ANN
�b PF4VAl� wEU, WARNER
.38721BoTTa,•-r cF 7�"s�6c E : 7 . 76
.07 X 1 y�5V ` '`�St�'��` ���N OF MgSsq
AL
EN SITE AND SEWAGE PLAN
i�
p Benchmark se 7/0 3
in boulder with No. 114 N L❑CATI❑N. Z S
aAe_ orange paint
E1.=91.60 (Assumed)
8.68 Scale. 1'=30' SANITAR\P� Cj G; PREPARED F❑R:
ti si - l
S�o ohP
8-
�p 61 "moo,, 0' 30' 60' 90,
SCALE:
DARREN MEYER, R.S. rf
DATE:
43 VINE ST.
DATE HEALTH AGENT DUXBURY, MA 02332
(508)362-2922
SAIL LOG
i
- N 0. 1
I T E PLANN 0•. Z ;
I 15,
5.8 0
O
3 4 -
_ 4 - - -
— TOP OF FOUNDATION El . : az.8� ----- --
` rEJiu�
6 s,4�1Q
7
--
_ 10 r— - A/Vv
r I N.E I J48a I N E L. 74. G v
r -
.
_ �s3�� 2 COVER V E R 1 $ 3 8 WASHED STONE
0 N E ;
N El } IN.El 7S,o - �__ — J, = - 4 -= R12
6�� SUMP IN E1.7 "� V- 3 4 1 t`2 WASHED STONE 13
4 LIQUID LEVEL .� O/B W/ 6 F ---+
�^ COON !�
14 I
T . t a i F 6" EFF, DEPTH -- 15 -J
a. a n� a• • LJ _
_ PERC TEST RESULTS
PRECAST SEPTIC TANK WITH "� PERC RATE : <
PRECAST LEACHING PITS L m/N oE,e iw�'N
CAST IN PLACE INLET AND
EL. � s. q° °- -==, w- -- NO.: SIZE : - = �, x E� �' 57iQV WHlTNESSED BY: _To/a2
OUTLET T "S PER TITLE V �� � I ' BOARD OF HEALTH I
� . , DATE:
j
O IA .
430.9 k D
j
1 i
i
I
PROFILE OF PROPOSED SEWAGE SYSTEM
i
�<_N5 Tft 6L 2
SYSTEM DESIGNED BY THE TOWN OF �F _ -_ REGULATIONS AND �s-
Ij STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE : 1/4 -- V 0
N . B .
I
1. All PIPES SHALL BE SCHEDULE 40 P.V.C . SEWER PIPE �-7-4
i 2. All PIPES SHALL BE SLOPED 1/4 " PER FOOT EXCEPT FOR •° /00% ,lE
THE FIRST 2 FEET OUT OF THE D /B WHICH SHALL BE LEVEL
a• -
3. DESIGN FLOW 4-. BEDROOMS AT 110 GALDAY PER BR . y _._ GAL / DAY
s
SEPTIC TANK SIZE -q4° _ X = GAL . �z) �cN�r's r,� fz -I�5 e z ��' g "ou . Zs-
A F O T F I
USE / so o GAL. W l ,,-�,TH A G � ,i °o°r'° x Q 94 s• E
II , _ 0 RBA E DISPOSAL AR 48,E �--
- --Z) 6• D/fl7, x G ' i�£EP P�t�FlS7" E�c'Niv r�/TS o
r-- i
LEACHING SYSTEM : USE 4 a z x
wIrAl /' 6F S7ON5 A<1- -?Rein/ �zr„ h
0 o
x �v x T
-z X8 x �gq°9 Ex5
EFFECTIVE AREA : SI0E'�)(a� X��) r (.Z71-¢ 6) 1,5 _ ls� _,.-;-,4C-4C,.gy q� � sz � wE� 5 � • I
I BOTTOM ��( -,�. � _ (�4 ) �.o_- ,00 G,��oAy
i TOTAL FLOW Bs3 G �6.5
I
TOTAL REQ 0 FLOW - _ X ___ W/ /Ty GARBAGE DISPOSAL 0
RESERVE FLOW Bs3 - 660 i93 _ GAL / DAY /ti -507 97c
REFERENCE PLANS : F�km Sueoivisia�• _ 18Ao A�G�vR �ArE)
c
fO� OLV /N4'c.
-
- - APPROVED BY : �P`jH°i M�sq� ����J OF
MASS�cyG
F BOARD Of HEAL T "BAST tiN
�DOYLE y 1 4v
DATE %sTE �FT6 -
PROPERTY OWNER : ___m�_ /JNl�__M eS __ Lr1 v iI> !� �N�:_ ---_ __-- ___ SgNITARlt 4�� S lS RI Ey fSITE AND SEWAGE PLAN'
BEDROOM SINGLE FAMILY DWELLING
r > i LOT : !vo, 25 Bo-PF15 H F/'Wt 5 — AnrGMCA 1)pj\1E
w
:• 99?!! DATE � u Y 28 1986 eEviSED; s�tJ6vST /�, /`j8G
, Sgp,TgRi
DOYLE ASSOCtATES fAIMOUTIt,, MASS ,