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HomeMy WebLinkAbout0028 DERBY DRIVE - Health 28 Derby Drive - -- W. Barnstable P A = 175 020 A i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Derby Drive i Property Address Wendy Marshall f Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection',' r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 64 /4q 14 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road �y Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 02/28/2020 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform lin the future under the same or different conditions of use. t5insp.dDc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This three bedroom house has an H-10 1000 gallon septic tank with an H-10 D-Box feeding into a leaching pit. At the time of the inspection there were no visible failure criteria found. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` . 28 Derby Drive V Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 c Commonwealth of Massachusetts �n p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive u— Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form tiI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow'based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gp ))� Detail: In 2019-68,000 gallons were used and in 2018-70,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form I s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title.5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection . Form li; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive V� Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form + �i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 8"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard H-10 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the bafle's were in place. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,,p Title 5 Official Inspection Form �Ib Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive V� Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts �n Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts I�.p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 28 Derby Drive u Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. At time of inspection there was 2' of leaching available and no visible stain lines above. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 28 Derby Drive u� Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Derby Drive U V Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) 14. Sketch Of Sewage Disposal,System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Driveway A OO C B O A B C Patio 1 13' 17' N/A ❑z O2 N/A 11' 25'8" 3 3 N/A 25'6" 26'4" t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 16 plus feet 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: augered a hole at lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 cam, Commonwealth of Massachusetts p Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Derby Drive Property Address Wendy Marshall Owner Owner's Name information is required for every West Barnstable MA 02668 02/28/2020 page. Citylfown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS. j EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR c DEPARTMENT OF ENVIRONMENTAL PROTECTLON 3 - 2002 F BARNSTABLE LTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A MAP " CERTIFICATION PARCEL ' 0 -- Property Address: c2 020 f LOT Owner's.Name: Owner's Addre oA,/%J Opole Date of Inspection: . Z94 ,;2QC>a� Name of Inspe ease rin t):'Company Namt�() Mailing Address p 1.2,7504a A- eLIA da�� Telephone Number:sj e- ' 4 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 Fa Inspector's Signattire: Date:The system system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a.shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at.the time of inspection and under the conditions of use.at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION"FORM PART A CERTIFICATION (continued) Property Address: Owner: . Date of pection: Inspection Summaryyyy`:'J1 Check AAC;D or E/ALWAYS complete all of Section D A. ystetn Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15'.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. " Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass'section>need to be replaced or repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please explain. 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..t:ank failure is imminent:Systern will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or 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: w Owner: Date of �pection: P�.�i�(./n,f �/I I'Doo 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 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 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 ' 1 Page 4 of l 1 OFFICIAL.INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q9 //LL Owner:. Q 2 =_ Date of ectioh:U_& 0Dl cgQoZ D. System'Failure Criteria applicable to all systems: .You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component 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 '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ' of times pumped _ Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a=public well. _ / Any portion of a cesspool or privy is within 50 feet of a.private water supply well. . 1 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,:provided that no other failure criteria are triggered. A copy of the analysis most 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 15303,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 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 P5.304.The system owner should contact the appropriate regional office of the Department. .4 i Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _Lys Owner: Date o14FtSpection: p Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No 1� Pumping,information was provided by the owner,occupant; or Board of Health l/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 f 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: Yes no 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 15302(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION Property Address: . Owner. Date of, spect on: . �/ 0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):- Number of bedrooms(actual), DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no) Is laundry on a separate sewage system(yes orho -[if yes separate inspection required] Laundry system inspected(yes or np)/2ff Seasonal use: (yes or r . Water meter readings, if available(last 2 years usage(gpd)): ��` 17 Sump pump(yes or n �cw / 06/up Last date of occupancy: - !� COMMERCIAL/INDUSTRIAIfl-� Type of establishment:. Design flow(based on 310 CviR 15.203): gpd Basis of design.flow(seats/persons/sgft;etc.): .... _ Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records � Source of information: X Was system pumped as part of t ie inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �ptic tank, distribution box, soil absorption system Single cesspool Overflow cesspool =Privy _Shared system (yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach'a copy'of the DEP approval Other(describe): proximate a e of al] componen s date ins ailed(if own. and source of information: Were_sewage odors detected when arriving at the site(yes'or no):,-,� 6 Page 7ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSU IF ACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date of pection; BUILDING SEWER(locate on site plan),%6&- .Depth below grade: .Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: 1/ (locate on site plan) Depth below grade: 169 Material of construction: (/concrete_metal_fiberglass_polyethylene _other(explain)_ If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: X 'X Sludge depth: Distance from top of sludge to bottom of outlet tee.or baffle: l� Scum thickness: D" _ 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 de,.ermined: W hj OVZ4 4D Comments(on pumping recommen ations, nlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): " O GREASE TRAP ovate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass__polyethylene_other (explain): Dimensions: _ Scum thickness: Distance from top of scum.to top of outlet tee or baffle: Distance.from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l 1 OFFICIAL INSPECTION FORM_NOT FOR:VOLUNTARYASSESSMENTS L SYSTEM INSPECTION FORM SUBSURFACE SEWAGE I)ISPOSA PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of pecti n: TIGHT or HOLDING TANXL_ g tank must be pumped at time of inspection)(locate on-site plan) Depth below grade: Material of construction: concrete metal fiberglass__jolyethylene other(explain): Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to"outletequal, any evidence of solids carryover, any evidence of akage into or out of box,ete.): _ P PUMP CHAMBER (locate on site.plan) Pumps in working order(yes or no.): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of l l , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: A s Owner: G Date of pecti n: �_�i �� a/� a SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, CESSPOOL. (c.:sspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY ocate 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.): 9 n Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a. Owner: Date of 116ecti& SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where`public water supply enters the buildin,. i l2) O ')C1 a S10 ,o Page 11 of 1.1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �1 � ✓Lf� Owner: 6� Date of pection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Z- feet Please indicate(check)..all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: "hecked with.local.excavators, installers-(attach documentation) 1/Accessed USGS database-explain: You must describe how you established the high ground water elevation: q e G 11 Permit Number: Date: Completed by:. ��1G HFIGi-; GPO•UND-VV.47,E•R LEVEL COMPUTATION Site Location..: ��� ��, ��� 1�' Lot N'o.` •R . Owner: � �� Ll� Add.ress-_ 914 -e_ Contrac or: l rde.51.- Address: G Notes:. /kl2X1a / Gi /lrJG/.S STEP 1 . Measure depth.to•watertable. _ to nearest. . I.t......_. ..................................... .Date month/Gay/,Year I ST E:P 2 Using.Water-Level.Range Zone i . and lhde.x Well,�.M:a.p locate site and•determi'ne: OAppro.priate.index well................-............... .._..:._-. J, I vWale--level ranoe zone:._........................._.._.-.._._......._'_,-_•• STEP::3:: Using•monthl•y.report.."'Current Water R.esourcestonditions" determine current-depth to water. level tor•indcz well ............................ J month/year S.T•.EP. q Using:T abie:D.;.Watnr,I.ev..el Adjustments Tor index well (STEP 2A),.current de.oth l to water level for. i-ndex well (STEP 3):, and water-level zone (STEP 28) I I �y 3- 1 determine,water-level adjus.tment .................................,..:..-.-...-_...........,................ ;,.:_.:.._...__..... �5 STEP: 5 stimate depth to:high water by subtracting th.e water- level adjustment.(STEP 4) from measured-.depth to.water level at si'te.(S T'EP 1) ............._............-..-................._.._....._..-_.................................... .............. 33 7 i�,ure 11--,Reproo--ducible Computation,i Fr i. i Ce'P AvP r, Ilfi I I S TOWN OF BARNSTABLE LOCATION L �,$ '` (.,;,`� ��,�„ �p Y SEWAGE # q 6 " 3 619 VILLAGE �,, ��A�� ASSESSOR'S MAP & LOT` \� INSTALLER'S NAME PHONE NO. , li'�c�j,�e �l- Q% SEPTIC TANK CAPACITY j (7 0 C) � r I LEACHING FACILITY:(type (size) J 00 o c NO. OF BEDROOMSZ-_PRIVATE WELL PUB IC WATE BUILDER OR OWNER S DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r - a • �� �> � � .ate No...... ._.. .6� 4 FEs..........................�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........10.U.1A..........OF....... P�17- /"s.Y .......:. Appliratinn fiar Diipniittl Works Cann#trudiun Prrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at •.............. T.. -- ..�... .z��t.E.........:� c �Vic_ --•-- .................... Location.Address ••--or Lot No. .............. .1 ! -::'.� .. t .l .............•- .......-•--••---•--.......---------. ............ ...................... • .. .. ,'Owner Address a ..�..�, ......------ = --------------------�.���1=----Address 1r � .....---................. Installer Address Type of Building Expansion Attic ( ) Size Lot-�r'� ....Sq. feet Dwelling No. of Bedrooms.......... ge Grinder Other—Type of Building No. of persons............................ Showers — Cafeteria '. a' Other fixtures ...:............................. ` - �Q ( tC� Design Flow.................. ................_...gallons per-powan per day. Total daily Kow....... Septic Tank—Liquid*ca acit .gallons Len h� .(, -.. Width:r.i . .��G�. ............ lops, Diameter................ De th... .. x Disposal Trench—No..................... Width.................... Total Length................,... Total leaching area....................sq. ft. 3 Seepage Pit No..__`............... Diameter....I?......... Depth below inlet........CO...... Total leaching area_Z42.`. Lsq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by.. ? ...G-t+.(C�-(_tl................... Date._gal f..... �r i i� Test Pit No. 1................minutes per inch Depth of Test Pit.... Depth to ground water...._....... 1 .. f=, Test Pit No. 2.... .....minutes per inch Depth of Test Pit....J LL..... Depth to ground water....t�.�t\t LJ,,, ........ j . . --•-•------••----.. scr a>� *CL.---- ----`...�... ..•- l � .r.a. 02. 1L�De x NJ 7 --•----•---....--••...................................•----•-----••-------• •------• l .... t.t ........................... UNature of Repairs or Alterations—Answer when applicable.................................................................:...............4............. ...............................•------.....---.....---•-••-•---••---•--••--.......................------•-----•-------------•-•-------------•-------------•--•--------------............................ Agreement The. undersigned agrees to install the aforedescribed Individual S age Disposal System in accordance with the provisions of LITL; 5 of the State Sanitary Ode— The undersigAe,4 fur .e grees not to place the system in operation until a Certificate of Compliance has s d the oa f h Signe .. .. .... -• . ••. •........................ ....,...a.t.e ...1wY�" � :APPlication A .. ......... ...............•-.••--- ....roved By......... .� "Date gS Application Disapprr' ed for the f lowing reasons:--...............•---...........-•--•------..•...................._..........................•--................. .......................... ....--•--•-••••••---•-•-••......••---------.................••.---..................-•••-•...•----•--•-•-••--•----•----••--•----•••---•......•--•..--•-- Date - Per . Issued.----------•....... - ---•--.--- ..... • Date _�r . . ........... THE COMMONWEALTH OF MASSACH".USETTS BOARD OF -HEALTH 1.40ratioll for �i o tt� ork C�onstriirtion Permit Application is hereby.made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at ............I::.- �.►.2...���._`���tTa��... .._.:�u):►`:c:�r.....c..................L�........................... Location-Address or Lot No.---- � 1�' wner( �� Address . .....-••-_..._- .............•-....4.......=- ._ ....................... Installer Address ! ..-3....S feet Type of Building Size Lot...... ......... .. q. 1-4 U Dwelling—No. of Bedrooms.._..._.._16 ________________ Expansion Attic ( ) Garbage Grinder ---- — aOther—'Type of Building.____________________________ No. of persons............................ Showers ( ) Cafeter- ( ) !Other fixtures .................................Q Design Flow!.......... Pe-s..:.�p.._.. roer day. Total dailytflow.....- "� � ...............gallons. gallons Len h Depth - ..- Septic Tank ; Liquid capacity >._g gt : _.._. Width �! ._ Diameter _._._,_ ... x Disposal Trench—No..................... Width.................... Total Length.....__......_}... Total leaching area....................sq. ft Seepage Pit No.....�••----------._. Diameter:...0.>......... Depth below inlet........ ......Total leaching area.Z .....sq. ft. Z Other Distribution box ( Dosing tank ( ) a Percolation Test Results Performed by.._ {i '?( F,A - ... k lr 1 ( ............. Date_.-._--'_--�!-1-1 L. .......... r. c Test Pit No. I................minutes per inch Depth of Test Pit._,_l_� _:_. Depth,.ty:.ground water_. 44 Test Pit-No. 2.....-_"�„�__-----minutes per inch Depth of Test Pit... ._..... Depth to ground water---k.11.11/ ........ .............................................. ......... O Description of Soil ...��' 47 ..7 ' `�CSCI .C(:A •IV� �k.�t= (\11 /<?1 o W .......................... ............................................................ „ �s� :_--__--l.t4e V Nature of Repairs or Alterations-Answer when applicable______________________ __________________________________ __________7.__.._............_.. ................................•--..,.........-...-----••-•---•-------.._•......---...............-----•-----------------------------------•--•---.._......----.-....------............................ Agreement The. undersigned agrees'to install the aforedeseribed Individual S age Disposal System in accordance with the provisions;of:ITL:; 5 of the State Sanitary de—The undersi ed fur .agrees not to place the system in operation until a Certificate of Compliance has 's d the oa f h 1 3 i Signe . ... . .... f ......---- :... . v;✓ ii APPlicatiori Approved By-=-.......... _ -••-•.-••-•-••-•-_-•--- ' ............ 1 v gS ..... .. . Date Application Disapproved for the lowing reasons:... ........ ................................................... ---••...-•--•-•---•-•.................,...--•---.....------•-----.•.........----•---•--•........----........---•--••....------•--.....-...:------.-.............------.....-----.._.................... I Date Permit No...............��..S,--• .•6-g .._._.. Issued....... .............................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH r �r Tertif i:ratr of` Tomplinurr ' TH,,�S/�Sj T RTIF�Y✓That t�!,Ja4ividual Sewage Disposal System constructed or Repaired by-..... .. .. ........... . __ .... ........... lnst ner at.--•---..... ....4;- ......... .�_+�z ....._G��,_�Cl::P.............(,�.a.�___----__�. .�1 ...... has been installed in accordance with:the per isions of TIT 5 o Th�j State Sanitary bode a desc�ri�bed in the application for'Disposal Works Construction Permit No.__., _ _ j� Lr.- .:._. dated --- T -Z- .. ,. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL �NCT �� �CTORY. DATE................. .- ......... Inspector -----........_.._....._.... .------------------•----•••---•--••- .............. II a-s�I»iny.i''a•�s++»»'.»n P'+n..»+.fi..r s n a.. »Mma My.t-e.e sr a ». r..l ... v»,.N.r.wa+Im ----------- THE'COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH ..........................................OF.... i:._ ,. �. „_..,. �y .►-- No........................ = FzE.............. �....... tt1 o���� �i/irtion '�rrmit Permission is hey granted.. - ...-•-•-•. to Constructer Repair ) a dividu 1 Sewag isposal Syst K� r • � Street � ` �'R�R � �, ��� as shown on the application for Disposal Works Construction Permit No., .- ..Vr Dat ._.�K ....... ......... i .......................... � � .................... ..............._ oard DATE................�...................................................... lof fie th - G SECTION - SEWAGE SEPTIC TANK- 13 _..D"BOX— `tf —LEACH .". ---- TOP OF FO laG �'� ..Z..OF t/aTO�h" , WASHED STONE . os - 10 I IN• OUT• IN - , r �O \ LO�r7 OUT• IN O 1 _ i 1- EPTI -Y-�'i+"� TANK, ELEV: ELEV. � bzlil ELEV. ELEV.t KM ws �2:.c7• y 1v \,1 WASHED STONE MM54 2 V W TEST'HOLE LOG P °I� q�,, _ TEST BY�I�KE�� �, Go111�01�. �2 ��/�� WITNESS J ✓ oµ' 1 -bp U' TEST DATE DESIGN . BEDROOM HOUSE w T.H.T.N: s. 1 2 ELEV.10&_5 ELEV.IOLI-1 NO II F LSp� J MINAN: DISPOSER DISPOSE /I�{ �I PERC RATE ` FLOW RATE (GAL./DAv) 33 0 ; H 1 � n G 1.1I7 Jul/ SEPTIC.TANK-'- .330 (1�51= — REO'D,SEPTIC TANK SIZE 000 i 102— F��4 E6 - M E , F1 I ti er 51 T LEACH FACILITY I SIDE WALL �rr62 154,Qj (2,25) G1�3 •G/D. M PGG'r BOTTOM C�L�Y' rr = 5 0 3 ;0 q2� G/D: - \Q. �0 u 3 TOTAL ', 20111 gF 5 .15 A/[) I '� \ f USE: 62*1 E LEACHING PIT WATER ENCOUNTERED ENCOUNTERED NOTES'� (UNLESS OTHERWISE NOTED) L DATUM(MSL):TAKEN FRO Sal.LPl%�I QUADRANGLE MAP OF IZE t]ls G'r OI�I 4F ------AVAILABLE ---- 2.MUNICIPAL WATER _ —3 WpE'P1TCHrN"-PER-FOOT a ARNE H. 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:.AASHO- !+� -44 - _._ OJALA I 7,�I S.MIN.GROUNDCOVER OVER ALL SEWAGE FACILITIES:(2)FT. 6'PIPE JOINTS SHALL BE MADE WATERTIGHT + �'" CIVIL I G� 1 �! �'.�, Na. 792 p Of 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. � STATE ENVIRONMENTAL CODE TITLE S - LOCUS SITE PLAN , L,oT 62 D5{��� A. yG, t� _ H: v1 , �I >dLl. ��I-SUITA•PJLt: FIAT IAl. 13F�TJ�� 1 EI,�v, Ie0.1,3 -------------- OJALA H - BEG.PROFESSIONAL ENGINEER N.M�18 REF: }., G4jS IZ�E TO 1✓I�f�l11M < t�.[7 � 101 �POI�} I I� -- } yoA� Cap PREPARED FOR: ��i�+ L�-O{otl�✓ CIVIL ENGINEERS BOARD OF HEALTH { LAND SURVEYORS BEG_LAND SURVEYOR _____ p SCALE SR`• OONTOURS (pRopTo�seo)-o-o-o-o- APPROVED DATE " � ��a� `MA ��'� DATE Pie5 —2 I