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0062 BARNHILL ROAD - Health
62 BARNHILL;Oa�j, WEST BARNSTABLP, A= V%- t�L1 e} i 31 G Nr ° ° Ir tj y� 'Commonwealth of Massachusetts l00 ' 0 a,:;L— Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, ter: 62 Barnhill Rd. Property Address rk. Wayne Pacheco Owner Owner's Name L information is / �`� required for every West Barnstable MA 02668 6/18/2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. 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 Paul Martin use the return Name of Inspector key. Cape Cod Septic Services Company Name 350 Main St Company Address re W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 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 completeras 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 6/28/2018 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ••�''r 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is West Barnstable MA 02668 6/18/201 required for every 8 page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition. 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): t5ins•3/13 Title 5 Official Inspection 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 M vay 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. Cityrrown State Zip Code 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 ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �A- 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform Lacteria 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 cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G„M ey` 62 Barnhill Rd.SV Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. City/Town State Zip 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 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments sV0'r 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. City/Town 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 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): 440gpd DESIGN flow based on 310 CM 15.203(for example: 110 gpd x#of bedrooms): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 ® No Water meter readings, if available (last 2 years usage (gpd)): N/A well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No records 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. ❑ Other(describe): t5ins•3f13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official a Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 .6/18/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 16"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 Sludge depth: 2-3 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 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 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal tank in good condition. Concrete baffles in place and solid. Tank at normal operating level. Covers 16" below grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. 4 Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 a e. City/Town State p Zip p 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M "t 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 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 off 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.): H-10 DB-3 with 1 line in and 2 lines out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 6" below grade. 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: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u -- v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 62 Barnhill Rd. M iuey Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. Cityfrown State Zip Code Date of Inspection D. System. Information (cont.) Type: ® leaching pits number: 2-6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-Leach pits with stone. No more than 2' of effluent in pits during inspection. No sign of overloading or hydraulic failure. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 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.): 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. CityrTown 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 Wins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 M I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Prior report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Prior report hand auger indicates damp soil at 15'. 6' separation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °� ••�" 62 Barnhill Rd. Property Address Wayne Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 6/18/2018 page. City/Town 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 `M I r Page 1 of 2 TOWN OF EA TABLE I.aCAT60pI YMLAOR Gqr_[ AAtgar r. AssMORS MAP a Lor&ALdm,a INSTALLER'S]NAME A PBO= Marm TANK CAP 68ACII GFACII.IT7,,(gpo WO.®P BED90OUs a';-Y A i Fe SUC WATER BUILDER DATE PRRJUT MUND: DATE COMPUANCE issue_ VARIANCE GRANTEDe Yes rr�-- -- 40 ! AS qro --3q j s Commonwealth of Massachusetts /00 L,9,;-7 2' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owners Name information is West Barnstable `"' MA 02668 1/12/2016 required for every page- City/Town State Zip Code Date of Inspection 0-6 fr+ Cn Inspection results must be submitted on this form.Inspection forms may not be altered in ant* way.Please see completeness checklist at the end of the form. fiffing out form A. General Information on the computer, use only the tab 1_ Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services as Company Name 350 Main St Company Address W.Yarmouth MA 02673 Cityrrown state Zip Code 508-775-2825 S15016 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1/15r2016 Inspectors 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. t5at9.3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys•Page 1 of 17 �D�� VS Commonwealth of Massachusetts Title 5 Official Inspection Form m, o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/12/2016 required for every page. Cityfrown 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: System in working condition. 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): t5ins•3/13 Title 5 Official Inspection 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 ° 62 Barnhill Rd. H Property Address Shane Pacheco Owner Owner's Name information is west Barnstable MA 02668 1/12/2016 required for every page. Citylrown State Zip Code 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 ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/12/2016 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ` ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 6% Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/12/2016 required for every page. Cityrrown State Zip 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 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/12/2016 required for every page. CitylTown 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 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 El ® 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): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/1.2/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information tion Description: escri tion: 1 Number of current residents: 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 ® No Water meter readings, if available (last 2 years usage(gpd)): N/A Well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Daterent 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/12/2016 required for every page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records 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. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 1/12/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 25-30 Years Est New pit added in 1995. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 28" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): 18" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500Gal H-10 Sludge depth: 3-4" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owners Name information is required for every West Barnstable MA 02668 1/12/2016 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 Scum thickness. Oil Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dime-isions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal H-10 tank in good condition. Concrete baffles in place are solid. Tank at normal operating level. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/12/2016 required for every page. City/Town 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: [IYes ElNo 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Common wealth of Massachusetts U W, Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owners Name information is West Barnstable MA 02668 1/12/2016 required for every 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.): H-10 DB-3 with 1 line in and 2 lines out in good condition. Some wear on box but still structurally sound Minimal solids carryover. No sign of overloading or hydraulic failure. 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.): * order, s stem is a conditional ass. If pumps or alarms are not in working p P P 9Y Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owners Name information is West Barnstable MA 02668 1/12/2016 required for every I page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-6x6 Pits with 4' of stone. 2'6" of effluent in 1 pit with 36" of effluent in second pit. No sign of overloading or hydraulic failure. 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 15ins•3/13 Title 5 Official Inspection Form: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 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/12/2016 required for every page. CitylTown 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-3/13 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 w 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is required for every West Barnstable MA 02668 1/12/2016 page. City/Town 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owner's Name information is West Barnstable MA 02668 1/12/2016 required for every page. City(rown State Zip Code Date of Inspection D. System Information (coot.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to 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: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger near pits found soils getting damp at 15' Bottom of pits is 9'. 6'separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Barnhill Rd. Property Address Shane Pacheco Owner Owners Name information is required for every West Barnstable MA 02668 1/12/2016 page. CitylTown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARMSTABLE LOCATMN & .ate IL SEWAGE 17 VIII AGE G.r- 19AA#%=tom: ASS=GR'S YAP&LOT&&d-,Ea nzsrALLEas mmm i mna xo,�?astrvom caw7— V =SStx4 SEPTIC TAN[CAPACrrY LEACMG FACRM:(type) NO.OFBEDifOOILS PUBLIC WATER BUILD m O 7 eau DATE PERMIT IMUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTEir Yes q+ Ham' httn://www.town.bmstable.ma..us/assessinW/ display-asp?mappar=108022&seq=1 1/11/2016 TOW, BORTOLO'I'1'1 CONSTRUC'1 ION, INC. TyOF T �F 45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CO CERTIFICATION Property Address: Date Of Inspection I / Inspector's Name: Own is Name nd Addres J CERTIFICATION STATEMENT: 1 Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection..The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.T1►e system: o Passes Conditionally t'ass �J Needs Further E In the Local Approving Authority ° Failure n Inspector's Signature f Date: i The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,(lie Inspector and the System Owner shall submit the Report to the appropriate Regional Office of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to(lie Buyer,if applicable and the Approving Authority. INSPECTION SUMMARY: A) SYSTF - PASSES: ✓ I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. Tile Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- (ration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic'Tank as Approved by the.Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): - 1 - x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than four 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. C) FURTHER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of Health in order to determine it' the System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy.is within 50 Feet of',a Surface:Water,,, .. Cesspool or Privy is within 50 Feet of a bordering Vegetated Wetland or a Salt Marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OFHEALTH•(AND;PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT-THE SYSTEM IS FUNCTION- .. 'ING IN A MANNER:THAT PROTECTS THE PUBLIC HEALTH AND,SAFETY AND THE ENVIRONMENT: The system has a Septic Tank and Soil Absorption.System and is within 100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public Water Supply Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well,unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm: D)SYSTEM FAILS: I have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload or clogged SAS or cesspool. , Discharge or ponding of effluent to the surface of1the ground or surface waters due to an overloaded or clogged-SAS or cesspool.:, Static liquid level in the distributionrbox above outlet Jnvert-due:to•an,o,verloaded or clog- r: ged SAS or cesspool: Liquid depth in cesspool is less than G"below invert or„available volume is less than 1/2 day'now. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - 2 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd or greater,(Large System)•and.the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system` �switl'in 400'Feet`of a surface drinking water,supply: ,.,.,; a,... The'system is within"200 Feet of a tributary to a'su'rface drinTdng water supply The system is located iii a nitrogen`seusitive area Ifi'terim:WellheadProtection Area (IWPA)or a mapped Zone 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. _None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _V As-built plans have been obtained and examined. Note if they are not available with N/A. jTile facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. . The site was inspected for signs of breakout.. All system components,excluding the Soil Absorption System,have been located on site. The septic-tankminholes were uncovered,openedj;an the_interior-of the septic tank was in- spected for condition of baffles or tees,material of construction;dimensions;depth of liquid, `,depth of sludge"depth of stun:" V The size and location of the Soil Absorption System oil the site has been determined based on existing information or approximated by non-intrusive methods. - 3 - - 1 F , SUBSURFACE `SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART B CHECKLIST(continued) IX The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ..PART C _ SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIA 2 Design Flow: al�l���f s mber of Bedrooms:! Nun ber of Current Residents:�J Garbage Grinder g JYpr aundry Connected To System: Seasonal Use:IJ6 Water Meter Rea n s if ailablVV e: g , Last Date of Occupancy: - C[� MERCIAI./INll J T 1 r•/0� Type of Establishment: Design Flow. gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: - - Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source infornialiiinc _4AUZI 7/�p System Pumped as part.of inspection: Alb If yes,volume pumped: gallons Reason for Pumping: TYPF,OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): AP ROXIMAT A E of.all o orient date in tailed(if: now�i)and source of information Sdvai Qors detected when arriving at site• -4- SUBSURFACE, SEWAGE,DISPOSAL SYSTEM•INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: / Depth below grade: 'Material of Construction: l/ concrete metal FRP Other (explain) Dimensions: .5 ' ' Sludge Depth: 4ell Scum Thickness: Distance from top of sludge to bottom of outlet tee or affle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,conditioin of inlet and outlet tRvs or baffles,depth of liquid level i elat' to ou inv rt�structura integrity e ' ence of kage,etc. GREASE TRAP:_ 6 ` Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: _Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or.liaftles,deptli of liquid level in relation to outlet-invert,structural integrity;evidence of-leakage,.etc.)--_-- TIGHT OR HOLDING TANK:_ Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid Iev 1 above outlet invert: Comments: (note i v_el a d di rib ion is equal,eviden solids carryove ,evidence f leaka a into or . t of box,etc.) �i h -� PUMP CHAMBER: ' Pump is in workmg order: -_.__ Comments:,(note conditfon`of pump chamber,co, .tion.of pumps;and ajipurtenances,etc) ' - 5 - .f y., r Y•4w•+e3 �:ia� )'.:5�..r.fie tiY,:q;=N - & i T, �t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): tx (Locate on site plan,if possible; excavation not required,but.may be approximately by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching Gelds,number,dimensions: Overflow cesspool,number: jPqniments: (note conidtion of s fl,signs of hydraulic failurelevel of po in ,conditio of vegetation,etc.) p CESSPOOLS: , Number and configuration: Depth-top of liquid to inlet invert: r'r Depth of solids layer: Depth of scumlayer: Dimensions'of Cesspool: i Materials of construction: Indication of groundwater: Inflow(cesspool-must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) a .. r a _ a - 6 - s- r fA ,,i �grS ����' /'ct. , '� t 1 •� ,fir• 4 �{ � +.� � t '� ,r�++ ���.�'.:S�����,+`r�,g 43+ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAIIT C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. /'/1 411 OD DEPTH TO GROUNDWATER: i Depth to groundwater: 31 Feet r Method of Determination or A pro,' �atiou: - 7 - m: CERTIFICATE OF . ANALYSIS Page: Barnstable County Health Laboratory Report Prepared For: Report Dated: 01/19/2000 ..Order Number: G0004765 Gordon Taroai 62 Barnhill Rd. West Barnstable, MA 02668 Laboratory ID#: 0004765-01 Description: WATER sample#: 04765-01 Sampling Location: 62 Barnhill Rd.,Barnstable Collected: 01/12/2000 Collected by: Gordon Taroz Received: 01/12/2000 Routine ITEM RESULT UrIlTS MCL Method# Tested LAB:IC Lab Nitrates <0.1 mg/L 10 EPA 300.0 01/12/2000 LAB:Metals Copper <0.1 mg/L 1.3 SM 3111B 01/13/2000 Iron <0.1 mg/L 0.3 SM 3111B 01/13/2000 Sodium 7 mg/L 20 SM 3111B 01/13/2000 LAB:Microbiology Total Coliform Absent P/A Absent P/A 01/12/2000 LAB:Physical Chemistry Conductance 88 nmohs/cm EPA 120.1 Of/13/2000 pH 6.0 pH-units EPA 150.1 01/13/2000 I Note: Water sample meets the recommended limits for drinking water of all above tested parameters. , Approved By: (Lab Director) Superior Court House, PO.Bog 427, Barnstable, MA 02630 Ph: 508-375-6605 TOWN OF BARNSTABLE LOCATION &tP /5'f-/t�Mu SEWAGE # VILLAGE 6V_ a,4/W ASSESSOR'S MAP & LOT/Pt--6�� INSTALLER'S NAME & PHONE NO./�a/67-0-"l G6N.5-T yIF= g SEPTIC TANK .CAPACITY Fr LEACHING FACILITY:(type) 1911 / N�`J(�-� (size) NO. OF BEDROOMS - � y VAT WE L PUBLIC WATER BUILDER O4'�� X � -- c DATE PERMIT ISSUED: ,�?/lam/ss-- DATE COMPLIANCE ISSUED: 1 .7— VARIANCE VARIANCE GRANTED: Yes N Ark - a® "► Fmc.... .8 ....... THE COMMONWEALTH OF MASSACHUSETTS t BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Di►ipotiul Wvrk.i Towitrur#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair (,< an Individual Sewage Disposal Syst/gJ, at: dd''JJ %/, 1 Vim! W .....................................................................••••-•-...-----......._...... .••.......................••••------------•---•••----•-•--•••---•..............___....._........_. otjLor 'on-Address or Lot No. -r o-GCy 1 .�". 7.a - 55 ...z..✓I��✓M I LC c..._. --•----------------------..�L� Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-------------ac ____ _______________Expansion Attic ( ) Garbage Grinder (�j �© aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ...-_-----_---------------- --------------------------------------- --------------- ............................................................. W Design Flow..............._5 _______._____gallons per person per day. Total daily flow.-____._-._.._ ...............gallons. WSeptic Tank—Liquid capacity/Pv_---gallons Length________________ Width_.____._..-_____ Diameter---------------- Depth................ x Disposal Trench--No. .................... Width_---_-....._________ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------./.......... Diameter-----16..------- Depth below inlet..__.6............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- ------------------------•••-------------•----••-•---•--•--------- Date........................................ W Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-.____.____.____-_____ ►" Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a ....---•------------=----------------•-------------....---•-----•--•-•--------•••-••••-•----•-...•-•-••-•••••......---------•---- ...... 0 Description of Soil........................................................................................................................................................................ x U ----------------•...---•-----------•--•-•-----------•-------...-----------------------••••••-•------•-----••------------------------------............................................................ 0 Nature of Repairs or Alterations—Answer when applicable-__;,A.Z-q......44-_--___-/,//o V--- �...��«?-f��................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance been issue y t board of health. Signed --------- .�1 ------- DaDue q Application Approved By ----- ------ -�-�-�c ............... -- �e../.✓-..-... Application Disapproved for the following reasons: -------------------------------------------------------------------------------------------------------------------------------- q Date Permit No. ....................... Issued .............. Daze .. .. J. ------------- � pp t� No....1.: __.027 v FRic U 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp iration for DinViniMl Wor1w Tomitrurtion ramit Application is hereby made for a Permit to Construct (System at: �)"or Repair ( an Individual Sewage Disposal ,. , - __ ,� ',. �:.� - ' �. •...........................................•-------------...------.....--------•--......._.------ ...........................-------------•------------•-•-•--------•-•------•---------•-•----•---- Loca Address or Lot No. = -�-��"'---,44CA ...-11 L� ' --................................(ry .l - ...... .. .... ------------------ �� Owner � .............................. /...--- C-��'�1J� -!! -ic�.� 7�.� �nl�'1��8 IGU /V1 t✓LI Il t - -- ----------------- '. � Installer Address I U Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms._-_-__-_-__�____�V----------------Expansion Attic ( ) Garbage Grinder Q aOther—Type of Building ---------------------------- No. of persons-------.__.----------------- Showers ( ) — Cafeteria ( ) QOther fixtures '------------------------------------------------------------------------------------- W Design Flow.................5� .............gallons per person per day. Total daily flow--------------�3_2!:;�---------------gallons. WSeptic Tank—Liquid capacitv/ a_G4 __-gallons Length---------------- Width---------------- Diameter................ Depth---------------- x Disposal Trench—No. .................... Width..............._---- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------- Diameter-----f4.-------- Depth below inlet.... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~" Percolation Test Results Performed by---------- --------------------------------------------------------- Date...................................... a Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ c� -----------------------•---------------------------...------------------.................................................................................... 0 Description of Soil----------------------------------------------------------------------------------------------- ------------------------•---------------------------------....----•----- x U -•----•---•---•---•----------------•---•-•-----------------....-------------•----------------------•--•-•---------•----•---••--------------............................................................ 0 Nature of Repairs or Alterations—Answer when applicable.___, D.�_..__,A---------f(/.f1.�1. t --- ` _Qj................ —----------- ....... ................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issue y thh board of health. / Signed / //'�✓I l-----��---- -- 1..C� r- - -- g Application.Approved By - .� ---`- -- '--�..- ............ ......... . ......................... -- .......... ---3. e ./�...... Application Disapproved for the following reasons: ----------------_------....__----------- ------------------- - - ..... - ...................... -------------------------------------------------------------------------------------------------........ -..................._._......_........................................ - ........ - ..............-- Permit No. ......CJ.,J. .......r.)- 7 Issued `j. -f�- d� Dare THE COMMONWEALTH OF MASSACHUSETTS iO G_ /yZ_ k BOARD OF HEALTH TOWN OF BARNSTABLE (1LPrtifiratr of Complianve THIS IS TO CE That the Individual Sewage Disposal System constructed ( ) or Repaired ( lam ) by ........_....- .............._..... �/(a—rrcu� C�,n/Y `it,�rt�--runJ _._-------------------- .......... ......... G ------------------------------- ----------- --------------/--------� has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....�5.r.�-..7_�/.......... dated __. .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... 947� ... - Inspect :.... ..---------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��. �� TOWN OF BARNSTABLE NO... . FEE---.....U_......... Permission is hereby granted............... ............................................. to Construct ( ) or Repair (%,<�j an InFuidual Sewage Disposal System atNo........................................ - ' u ft.l..l... . (``1 Street _ as shown on the application for Disposal Works Construction Permit Nola__-�_7 __ Dated--------- �--- ...... ---------------------------- _'K --- -------------------------------------------------- �j Cj Board of Health DATE.......... - ` ` ---------------------------------------- FORM 36508 HOBBS R WARREN.INC.,PUBLISHERS O o•f/ No....... �:..... , ` Fps.... ... ... . THE COMMONWEALTH.OF MASSACHUSETTS BOARD H ALTH Appliraation for Diapas al Works C omitrartion thrmit � Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal / System at Location-Address t or Lot No. ..............•-•_... �..H.Y:'ts�.l.......1�'1c.1�. .Ft ••-••••= --•...-••-••-•--•--•--••--•-........••-••••••-•-•--...••--•-••••---••••••--••••-•-........._..... Owner Address .._ � - Installer Address Type of Building Size Lot-_.3..R.$.&.7.__Sq. feet g ---=-------------- p ( ) Garbage Grinder ( DwellinNo. of Bedrooms______________ Expansion Attic Other—Type of Buildin a yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures -------------------------------•-----------•--------------•--•-----------•---••-------•----=-------------.....----.....---•----......--•---•-----•--- W Design Flow......... , ..........................gallons per person per day. Total daily flow...................... .:3®__..._____.gallons. WSeptic Tank J-Liquid capacityY50.Gjallons Length................ Width................ Diameter................ Depth........_....... x Disposal Trench—No_ ____________________ Width..................... Total Length.............�_.:...Total leaching area....................sq. ft. 3 Seepage Pit No..../............... Diameter...... b_....... Depth below inlet...... Tota lea cl1 area__..Z.G.6...sq. ft. Other Distribution box (/ ) Dosing to ) �(/ �} '. /r C� Percolation Test Results Performed by.---- _- ,, ..�i..Gv!.-�L-:------- Date_..�1'_C -. d a - i r _ Test Pit No. 1.......r0__.....minutes per inch Depth of Test Pit...... Depth to ground water......Pd....... __- (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ o Description of Soil x �` �: . 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 TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued 7b the board of healt , Signe - !�- !.2_� Date Application Approved By....... .------------------------ Date t •c . Date Application Disapproved for the following reasons----------------------------•----...--------------------•------------------•------••-•-------•-•-._.....--_...-- -•........................•••••--......•-•--•------•-•••-----.......-------•-•----------.....__._....-•-•--•-----•-------------•--•------•-----•-----•------•--------••....--------•-----------•-•--.._. Date Permit.No.---•--•-•-••-•-...----••••---•••-•••-•••--•••-.......... V4 ♦ Issued.-••••••---•-----•nab'--•-- No................2:..... Fizic .. o............. THE COMMONWEALTH'OF MASSACHUSETTS BOARD Of HE L - .r ......OF:........... . CGS' ------ .:;...........--..._......._.. :z Appliratinn for Disposal Works Tunstrnrtiun Prrmit Application is hereby made jor a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• ` ........................_....f.... ��. ............................................... ....................................................... :........................................ rLocation-Address or Lot No.+ r .. ►.. 1 /�/ Owner Address .............._::Y' .......... t...--------•-----......--•---............................. ...................................................... Installer Address Type of Building Size Lot.... �;�.�_._.Z.Sq. feet �., Dwelling�'No. of Bedrooms...............� ..........................Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of persons .:.................... Showers — Cafeteria w t,yP g P ( ) ( ) Otherfixtures ........................................ =--•--------••---••---••••---•••••----•-•-------••-----•..........................•---......-------•--•-- W Design Flow.... _.._,. �.........................gallons per person per day. Total daily flow......................K;go..........gallons. WSeptic Tank 4 Liquid capacity.,50.qallons Length................ Width................ Diameter................ Depth................ . x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._../.............. Diameter....../G-........ Depth below inlet......_....:_. Total Aeacl rea..-2 66..sq. ft. z . Other Distribution box (j� ) Dosing,,t,a'T� /��'} �� '—' Percolation Test Results Performed by-_.._..(�U�fZ�._ .._ ......... Date..._. ............................... Test Pit No. 1........ .....minutes per inch Depth of Test Pit......�.�.._._... Depth to ground water.4_._g a------- _ GL, t Test Pit No;, 2_"t.........._minutes per inch "Depth of Test Pit.................... Depth to ground water........................ - ----•-----.. .--•-............•. f. �y� D Description of Soil......... .�. ' .... .�.a Cis` 4`' x /S' ti�C, i r. ------------------------------------•-----------------------------------------------•-• rn •-- •---••......••--••--•-- UNature of Repairs or Alterations—Answer when applicable-----..: ...................................................................................... Agreement: �;.:. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System iin accordance with ' the provisions of TITILE 5 of the State Sanitary Code— The'urider signed`further agrees not to place the system in ' operation until a Certificate of Compliance has been issued b the board of healt r /* '}Signe .• . ...... ... ...[,�l... --•--•.I•-•............. _.._. Ye Application Approved By...•. .. �'... --�............•� ... ...'---------------------•-. ---� __�.._..... ..� . '.;4{ Date Application Disapproved fo Fthe following reasons_____________ _________________________________ Y Date Permit No-------------------.................... r-7 ,;� I su ..................................... .... D --•---•-----------•--=--------- ate is THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEAL H t .;.../'4-(.mil OF , G���r.�ilG�!G�'�f'............................ �TOR/rFY, (Enrtif iratr of f�um �i�anrr TH Shat the Individual Sewage Disposal System co structed ( ) orRepairedY ._ .. / .. . In$tal/lefi at.......... /P ..... ........... .....:........................................ n., has been installed in accordance with the provisions of T 5 of The State Sanitary de as described in the application for Disposal Works.Construction Permit No.. .................................. date?�IUARANTEE _ ..5___/__?._THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE®AS THAT THE SYSTEM.WILL FUNCTION SATISFACTORY. DATE . y Inspector ��--%����........ • -•.... ......... t THE COMMONWEALTH OF MASSACHUSETTS BOARD OE HEALTH }' OF..... ................... iw No...... Dispusa. AUorks , i trartiun rrmit Permission ' reby granted. ------•-•_ I- .......................... ,..................... ............ to Construe Or Repai ( ) an ii v u S .��a �e pi osal Sy 1 i at No. G:�__.... f�'��.. 4 l L ...................... Street as shown on the application for Disposal Works Constructin�- t No. ...dr------- Dated... ......�.. ?.-._S... ..............._......_.Board of_Health - DATE.........=.................................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS jj if •tt, { IN { L� in t� { i t 4.z-� �2.6q- _/. i _ r,1 zi d. J. ia► <.. *_-.�.• •— _, iti,.,••i—� _ 1,'- -�""^-S P' ,. •gyp �., rI i Mrs �Q�-vt, -y �:ti_ � �. � � , ' • Y • yr�w.:r.rr}+k�..�vw.¢..rw!.iw..• +{ P ` �� 7 T - a •. � •sw►w�M�w�+" e Y . ��•.. iA..i`(,{+/��i�f 5 �. 'iM �,. ' LA-ix 5 i Y t ', i . s3L N �l V�� n r 4f 's 'l.�jy"►frw "; �4"'r �+y+k is - �4f� ;f., •S r~'r b r� r � i .} �•wf�4 ply �',YL ram. ��.� "7 .•A_ a !! � ' r ¢*.#' _... .. r r .tis.y 'i r r�� i4. .-. p �,,��•( •� ��o'�', �. 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C*a �•`?r ����p.. `• � *� •r' ��•�•°�� f°�;��x�'Y' K •1r �4�+�1', ;t�� �t'.,» z • • • 1iI•\'rw J "�}y��, }`,�/�1 !y'''...�(� •./LiL{T ,] :/�w r 2's Y 4 • t+�y, °L ■ ]y }} S - �` YV�►}•dI [..Y„I�'{.�1-'"�; ♦ �r!',Y y��l��'� ••I� 'sri�,��I ��\y{"'.r••�✓ f'1{` f • �{`'_'t�� ` ` •» .'�I.\ Y�#.�RT �••�1.✓Sy:# � �►r•'+.tr� I �8. ."��'#��. ��.�.�f� �f T.•'�� . � °1 r � .. '�:+_ f.n+6- _ •r'�1 ��/y"t1 �•++►AJ�i A`• �*t{�.'�' .� •! •J i't* !11a�1 �%� � -�� • ' �t'�•t► y1..7. .. � �n f r.r { `�k # ���"• :w ��� �'t` ' •.� ►F4'�r�1 +; 1? Y - '}1' Ir� �iR _'1• " • L•� � •4 5 r `{ r•(�•�j�M� t. h y N l ° 1 ,` P. 1 .R � • i•` t7 ,T.4 µr•t S-�V VF � �r JN`\' sr, �;�1 J ` 1 �-[ 'L{f»'t v .. t'��•�- �r`'sFi•j.�" } { -.X.. � r � d �t -s r :'ha Yaa< .:e.��.+t.�'4 w a {,y,t„' y i.� ? � Y•�K ,,.t �;`;{' ��' L,i t�r�. .� ✓ '� ,� - r ;�: f s1f, L1 .� y, v - ' Yi � �•4i'. 4. <` }���+• �� �tP •r � r" �••h! i�`s''y �� rjy/�-i�i ; „�1/�P�. ' �i '` W't [� � ♦t it [ PA i.» r1F 2- D� L.0 C A T ION �' "r'1 a W A G E PERMIT NO. V'1 L L AG E AMM MAP 0 ti PAKEL No- ® n Z INSTA LLER'S NAME i ADDRESS ,Rro j �A, -+ �c ��s Co, IAC . o _ 2UILDER OR OWNER `DATE PERMIT ISSUED � �DAT E COMPLIANCE ISSUED �.. I 0