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HomeMy WebLinkAbout0017 HOLWAY DRIVE - Health 17 HOLWAV DR., W. BARNSTABLE „ 0 t. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owners Name information is WEST BARNSTABLE MA 02668 11/25/14 required for every page, City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in an P Y Y way. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms (� on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK L WHITE use the return Name of Inspector key. BOUSE HOUSE ENTERPRISE INC Company Name PO BOX 492 IL Company Address FORESTDALE MA 02644 City/Town State Zip Code 508-888-2010 S 113381 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 h R 1 310 CM5.000 . The system: ( ) Y `\`���P�jt-1 OF Ibfgs'iO�i ■❑ Passes ❑ Conditionally Passes ❑ Fails �`o MARK s9�yc' WHITE ❑ Needs Further Evaluation by the Local Approving Authority No.S13381 y •FRTIF\� '0�.��• S INS? NOVEMBER 25, 2014 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 daysof completing this inspection. If the system is a shared system or P 9 P Y Ys 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-11/10 Tttle 5 Official Inspection F S urfaoe Sewage Disposal System Page 1 17 f T Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 11/25/14 page. City/Town 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: 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" N ND for the following statements. If"not Y ,n' ) 9 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•11/10 Title 6 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 17 HOLWAY DR Property Address FRED LEGATE Owner Owners Name information is required for every WEST BARNSTABLE MA 02668 11/25/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owner's Name information is WEST BARNSTABLE MA 02668 11/25/14 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 rivate water supplywell". P 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. ❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow t5ins-11/10 Title 5 official Inspection Forth:Subsurface Sewage 01sposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owner's Name information is WEST BARNSTABLE MA 02668 11/25/14 required for every 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: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion.of a cesspool or privy is within a Zone 1 of a public well. ❑ El 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ 0 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. t51ns•11/10 Tide 5 official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 1 ' Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owner's Name MA 02668 11/25/14 information is WEST BARNSTABLE required for every 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 El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ 0 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) El ❑ Was the facility or dwelling inspected for signs of sewage back up? [D ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El El Were the septic tank manholes uncovered opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El ❑ 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: E ❑ Existing information. For example, a plan at the Board of Health. 0 ❑ 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: 4 4 Number of bedrooms (design): Number of bedrooms (actual): 440 GPD DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR ir Property Address FRED LEGATE Owner Owner's Name information is WEST BARNSTABLE MA 02668 11/25/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? M Yes ❑ No Is.laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: WELL WATER Sump pump? ❑ Yes M No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holdingtank resent? Yes No P ❑ ❑ Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5lns-11/10 c Title 5 OfHdal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ Ij Title 5 Official Inspection Form Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owners Name information is WEST BARNSTABLE MA 02668 11/25/14 required for every pace. City/Town 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: HOMEOWNER-PUMPED 5/13 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: n 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): t51ns•11/10 Title 6 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owner's Name information is WEST BARNSTABLE MA 02668 11/25/14 required for every 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: 5/21/86 PER INFORMATION AT B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes Al No Building Sewer(locate on site plan): 31't Depth below grade: feet Material of construction: ❑cast iron ■❑40 PVC ❑ other(explain): 200+ FEET Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): MAIN LINE IS CLEAR, NO EVIDENCE OF ANY LEAKAGE AND THERE IS PROPER VENTING Septic Tank(locate on site plan): 23" Depth below grade: feet Material of construction: no 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: ou Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owners Name information is WEST BARNSTABLE MA 02668 11/25/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 50" Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness 1411 Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle SLUDGE JUDGE/TAPE MEASURE How were dimensions determined? Comments (on pumping recommendations,`inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): INLET TEE AND OUTLET BAFFLE IN PLACE. LIQUID LEVELS ARE APPROPRIATE IN RELATION TO OUTLET INVERT AND NO SIGNS OF ANY LEAKAGE IN OR OUT. 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-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 ' Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owner's Name information is WEST BARNSTABLE MA 02668 11/25/14 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: ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts _ Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owner's Name information is WEST BARNSTABLE MA 02668 11/25/14 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): JUST ABOVE OUTLET INVERT Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX IS IN GOOD SHAPE, NO SIGNS OF SOLID CARRYOVER OR LEAKAGE 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Offlclal 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 17 HOLWAY DR Property Address FRED LEGATE Owner Owners Name information is WEST BARNSTABLE MA 02668 11/25/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 4-500 CHAMBER leaching chambers number: f ❑ 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.): NO SIGNS OF HYDRAULIC FAILURE, NO PONDING OR DAMP SOIL CONDITIONS. NO STANDING WATER Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property address FRED LEGATE Owner Owner's Name information required for every WEST BARNSTABLE MA 02668 11/25/14 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•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'r 17 HOLWAY DR Property Address FRED LEGATE Owner Owners Name information is WEST BARNSTABLE MA 02668 11/25/14 required for every 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•11/10 Tide 5 Offlclal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ' Commonwealth of Massachusetts _ Title 5 official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owners Name information is WEST BARNSTABLE MA 02668 11/25/14 requ red for every page.. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑■ Check Slope ❑� Surface water ❑■ Check cellar ■❑ Shallow wells 12' 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 JANUARY 14, 1986 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: GROUNDWATER INFORMATION WAS TAKEN FROM THE TEST HOLE DATA PERFORMED ON JANUARY 14, 1986 WHICH STATES NO GROUNDWATER AT 12 FEET S Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of-17 f Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 HOLWAY DR Property Address FRED LEGATE Owner Owners Name information is required for every WEST BARNSTABLE MA 02668 11/25/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist R Inspection Summary:A, B, C, D, or E checked ❑� Inspection Summary D (System Failure Criteria Applicable to All Systems)completed 0 System Information—Estimated depth to high groundwater 0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t51ns•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 z7 PIS Li i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 17 HOLWAY DR. W. BARNSTABLE 136-040-LOT 25 Name of Owner MIKE PEZZA Address of Owner: SAME Date of Inspection: 12/10/99 Name of Inspector:(Please Print)JOHN GRACI l am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a Telephone Number: n/a 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Eva ation By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:12/12/99 The System Inspector sh II submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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,the 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 the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.RECOMMEND RAISING COVERS TO SYSTEM. revised 9/2/98 Page 1 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 25 Owner: MIKE PEZZA Date of Inspection:12/10/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n(a 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n(a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection:or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa 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). broken pipe(s)are replaced obstruction is removed - distribution box is levelled or replaced nla 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 25 Owner: MIKE PEZZA Date of Inspection:12/10/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS 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 free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine-distance n&-(approximation not valid). 3) OTHER Wa revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 25 Owner: MIKE PEZZA Date of Inspection:12/10/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No X Backup of sewage into facility or stem component due to an overloaded or clogged SAS or cesspool. � h' Y � �e � X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 tim es in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X An portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation Y P P Y � P P vY 9 X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd 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: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 25 Owner: MIKE PEZZA Date of Inspection:12/10/99 Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at BAK X Determined in the,field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. J revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-0404-OT 25 Owner: MIKE PEZZA Date of Inspection:12/10199 RESIDENTIAL: FLOW CONDITIONS Design flow:-ilQ g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 44Q Number of current residents:2 Garbage grinder(yes or no):YU Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no).-_NQ Seasonal use(yes or no):JW Water meter readings,If available(last two year's usage(gpd): Wa Sump Pump(yes or no): MQ Last date of occupancy: n(a COMMERCIAL/INDLISTRIA Type of establishment: n[a Design flow: Ida gpd(Based on 15.203) Basis of design flow: nla Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n(a Last date of occupancy: n& OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: BUMMER_Lq99 System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nia_ gallons Reason for pumping: n(a TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE'AGE of all components,date installed(if known)and source of information: 1986 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 25 Owner: MIKE PEZZA Date of Inspection:12/10/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2_6_ Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: 2 Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ Wa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle: M Scum thickness:Z Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Jr How dimensions were determined: MEASURED Ccmments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _.Polyethylene_other(explain) n1a Dimensions: Wa Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:-n& Distance from bottom of scum to bottom of outlet tee or baffle n1a Date of last pumping: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Wa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 26 Owner: MIKE PEZZA Date of Inspection:12/10/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n(a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nta Capacity: x9a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:j3La- Alarm in working order:Yes—No—: NQ Date of previous pumping: n1a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Deoth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE Comments: (node if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa. revised 9/2/98 Page 8 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 25 Owner: MIKE PEZZA Date of Inspection:12/10/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n& Type: leaching pits,number: n& leaching chambers,number: 4-FLOW DIFFUSERS leaching galleries,.number: -n/a leaching trenches,number,length: nLa teaching fields,number,dimensions: nLa overflow cesspool,number: n& Alternative system: n& Name of Technology: jiLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE FLOW DIFFUSERS APPEAR TO FUNCTIONING PROPERLY SOIL PROBED DRY IN LEACHING AREA CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: nLa Depth of solids layer: n(a Depth of scum layer. n& Dimensions of cesspool: nLa Materials of construction: nLa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:nLa Dimensions:n& Depth of solids: nta Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa revised 912/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 25 Owner: MIKE PEZZA Date of Inspection:12/10/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a �e�h 10 a p c b ° w s AA y AB 6c. 1a ( A p fir! DA 3y Bg �� revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 HOLWAY DR.W.BARNSTABLE 136-040-LOT 25 Owner: MIKE PEZZA Date of Inspection:12/10/99 NRCS Report name: n& Soil Type: n& Typical depth to groundwater: WA USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratinn for M-4pniial Work.6 Tomitrnrtinn ramit Application is hereby made for a Permit to Construct (VI or Repair ( ) an Individual Sewage Disposal System at '7... ._.. > �1 ..-----. . .....N��d..�--------------------- -___--------------_------_-____ ,.... Loc ion-Ad ess or Lot No ::.: :. ..11�AN ••••--••-•••-•-•--•---•• Owner Address a ..................... ......_......_•---•-......---•-•--••-••••--•••. --..__.....-•-•---/I?p�,s r oz_t22_v ._._ --•----............_.... _------------------------------ Installer Address U Tape of Building Size Lot-�._. ?-0_12...Sq. feet Dwelling—No. of Bedrooms.____"..................._.............Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of persons____________________________ Showers — Cafeteria dOther fixtures --------•-------------------------.................................................... ..._.____.gallons per person per da . Total dail flow_____�rl/U_'_____ _ _� gallons. --------------------- DesignW Flow.............. _��- g P P P �' ,y � -------------� WSeptic Tank—Liquid capacity/- ?_gallons Lt ngth_A Width_._ _" Diameter__-___ Deptl_,:5_�_.__- x Disposal Trench—No. ....../........... Width...../®....... Total Length-----3..4_______ Total leaching area__4®y......sq. ft. Seepage Pit No---------------- iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (e Dosing tank ( ) `-' Percolation Test Results Performed by...t _N(ef,!/ ,�UlcJf� ______..___ _/� �� a Date. { -------- ------------ • - Test Pit No. 1___ __..._..minutes per inch Depth of Test Pit..___1. .______ Depth to ground water._ 0-4 rs, Test Pit No. 2................minutes per inch Depth of Test Pit-----AL'______ Depth to ground water_______ �+ --•------••-•-- •� -----•---•-•-•••-----•-•-----•-•••--•--------- -----•--•------------•-•-----••--------- 0 .7 e! . .Z?�� P� �® ROGER G Description of Sotl_.. -.._®" ... -------Z--••••••----•----•-••-•••--••-----•--- �3- -------PAUL C '4 --------------------------------------. f .....--------.._._......__ mo��aNlEvvicz W -------•------------------------------------------� �zozvti c-F , yc�tJ No. 0�0 U Nature of Repairs or Alterations—Answer when applicable____________________________________________________________________ ____ G� Agreement: y g The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in cordanc- with the provisions of TITi LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation a Certificate of Compliance has been issued by the board of heal h. kSigned:�•-•- -- .. ......�� - -_•`3---� � Date pplication Approved BY .-•-- ----•---------------- 3 1 ��- D ate Application Disapproved for the f ollo reasons------------------------------------------------------------------•- --=--------•------•-••-•--- •-.................••-•-------•----•--•••----•-•--•-•---•--------••---•-•••--•-••---•-••••--•--••...•-••••---•-•---•--•-••••-----••----•----••--••--------------•---•-•-----•••---------•----•--•--••-••- Date PermitNo......................................................... Issued_....................................................... Date No.•-•••-••--•-••._....... FEB.............................. z. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------ .a--� .......OF...... .Y .ST Appliratiout for Bgipoaa1 Works Tonstrnrtion 1hrmit Application is hereby made for a Permit to Construct (y) or Repair ( ) an Individual Sewage Disposal System at: .......... .................................................... s---...--- .f. Location Address or Lot No. .......... .__..__.. ......... ... ...... ••-__^._..........._.__....._....._ . j1; __.._......................_......____..........____.......•......._......_..•...... Owner Address W Installer Address d Type of Building Size Lot__S_Z0U...Sq. feet Dwelling—No. of Bedrooms.______________________________________Expansion Attic ( )' Garbage Grinder P0 a` 4 Other—T e of Building No. of ersons_______________r!. rl YP g `---------------------------- P - ------- Showers--(----)--- Cafeteria (----)- dOther fixtures .----•------------------------------•--•-------------------------•-•-•---•---------------- W Design Flow..................J- .................gallons per person per day. Total daily flow..`?X_�����__ 7`�.._gallons. WSeptic Tank—Liquid capacity/�agallons Length__ U�lo__��Vidth., f Diameter__�".......�D/ej)th__5_�0''_�' x Disposal Trench—No........./________. Width...../D.__..... Total Length..._J�__Z_.____.__.Total leaching area__`z_`_'_ ....... ft. Seepage Pit No____________________ Diameter------------.------- Depth below inlet.................... Total leaching area..................sq. t_t. f Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by---,2a�A._.11.4 !_�CcJ�G l/_.� w ��-- Date �P _ - Test Pit,No. 1_.`n 2__minutes per inch Depth of Test Pit..... T_____ Depth to ground water_ 44 Test Pit No. 2................minutes per inch Depth of Test Pit----- Depth to ground water.__ ___ " 04 •-••---•----•--•----•---......•.......................•--------.._...-----------..... -•----...-•-•--......--------•-•-...._._.__ .... - R g' ---•-- ••--�3.OGE G OUW r ' P AU Lescrptonooil...... ...... .... o .......................... P. ...----- ---------••--------------•----•. W C W1LNIEN IC Z ..................•---•.._...•-••-----•---•---•----••............. 4-----------------•----------- ... ---- p.3o420 - �`-- a� Navl� -•---•-•--•------------------------•----••------•-- .................. -- ---- - - - ?� x U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------_......................... _ Agreement: The undersigned agrees to install the aforedescribed Ind�vi(�Ual Sewage Disposal System in ac dance w the provisions of'T'LJ 5 of the State Sanitary C dew T9 undersigned further agrees not to place the system in' operation until a Certificate of Compliance has been sued b the }057 9�ftl'ieallt. g� pplication Approved BY---------------•-•-- ----•-•--•••............•. •_...-• -••-••--•--•-•---••-•--------•---- ---•••-- --- ---•-•-- Date Application Disapproved for the f ollowin reasons:-------•--------------------------------------------------------------- ...................................... ----------------------------••--•--•-•--..._..----------------•--•-•-•-----•---------•-•---•-------•-----......--...----•-............--•-•----•--••-•-•------•-------•--•----------•--• .............. � I Date PermitNo......................................................... Issued...................... .......................... - Date THE ebMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH b " �rr$i�irtt�le Iaf �um�li�nrr _ THIS IS TO CERTIFYt That the Individual Sewage Disposal System constructed (X or Repaired ( ) by.........gz�-oP4------- 12 ----------------------------------- --------------------------------------------------------------=------------------------------ In�taller 0 has been installed in accordance with the provisions of 'I'__ 5 Ot The State Sanitary L e a described in the application for Disposal Works Construction Permit No-_-____ '' 6_'"_ Via________ dated_.".__ -_2'�749�D—_______- j THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .....___. Inspector DATE............... � .�._1.�., .� ... ---- '-- N CC LE 7-Tf a THE COMMONWEALTH OF'MASSACHUSETTS BOARD OF HEALTH © aG No......... FEE........................ i �a or SSyst rrmit }` Permission is hereby granted__________________________ __ to Construct ( �ir Repair ( ) an Individual Sewage Disposa � w 1 v J�? tZ S }��sL 1� at No.- •--��.... --------I)_.t3.1M.f.•----------._4__ 5�.._... � � � �- .: t...•`*a. 7, Street .-as-shown on the application for Disposal Works Construction Permit_ No....... _ J ed---- ...................... a ------------•--••.. . —oa-- -- Health------------ --------- --------------- •-•-- FORM 1255. H-88BS &"WARREN, INC.,.PUBLISHERS _ 3261 Main Street Route 6A Barnstable Village MA 02630 . . May 21, 1986 Barnstable Board of Health 617 362 8133 Town Hall 367 Main. .Street .Hyannis, MA -02601 Re: Subsurface Sewage Disposal System Lot 25, Holway Drive, West Barnstable (Our job #03.1703.01, Leckstrom) Members of- the Board: On May 20, 1986, this office inspected the, completed' septi.c system at the above referenced site. The system substanially complies to the design plans prepared by this office dated January 14, 1986, revised on March 26, 1986. However, please note the distribution box was raised to better accomodate future access. If you have any questions, please do not hesitate to" call me. Very truly yours, BSC/CAPE COD SURVEY CONSULTANTS Ly Engineers o„ e r "P. 'Mid Lew�lc Z, PE ro ject _Nana er Surveyors RPM/mg Scientists 2 rpm3 Architects Landscape Fiea per, Architects O Tam dt Bmobb Planners D MAY 2 2 19 Cape Cod Survey Consultants LO v ON �-f-. 2f'" 5EW6,C4E PERMIT UO. VILLAGE ��s� IhlST�LLERS IJ�,P/lE � ADDRESS BUILDE^^R 5 tJ &MF- ADDRESS — — (�� r' saw4� f ��f� �� � — — — — DATE PERMIT ISSUED DATE COMPLI W-ACE ISSUED : 1 1 /�flits� �olaS 9 D �1 f SSES5OR'S MAP N0: PARCEL 'Z" LOCATION /7 SEWAGE PERMIT��NO.. 4-0 V LLAGE I N S T A LLER'S NAME A ADDRESS (� 5,01 vo E 4 B U I L D E R OR OWN ER bo DATE PERMIT ISSUED 27 DATE COMPLIANCE IS SUED ��, / ZS J ,® C ft ww 001 _r__ Jr, "J'A' ? A 4x'A" "Z, !v, A t- 'T? 'T-PS7" Pf�' ATA . 1P --TA" Dt 91BUTION B 0" A" D E_ R.wo �f"A 7 E 21 "AN IL SOIL I ILWA, I rM tKaKIATES K Lk_ 4 OBSERVED .4c, -1 V NOT TO SCALE NOT T!0 SCALE 7E.1 3140UNDWATCR V, 16, NOT ES� s, $EPTX; TAW, SHALL SE S�Elit_ 4� INLET' 00 OVTLET TEES TO Ak CAJI��T IRON Q R J4 -2, 1 NO. O�� OUTLETS-, ;P, RE%*FC)RCED COKPETE�, SCHEU 40 PVC� TEES 'TO BE C E",N T E R E D UNDER 'r P TP T TP 2, SEPTX; TANK TOW!THSTAND H­10 LOAOIW� MANHOLE COVER, GIRD, E GRD. GRO� E1. GRD� GW. EL_J�� TRAVELED WAYS,W)4FRF',N H-20 LOAOiNG, UNLESS UNOrR RAVEMENT, DRIVES OIR UANLESS UNDER PAVE-MFNT, ;)RIVES OR I. DiST DOX TO WITHSTAND H-10 Lf_-;ADiWG GW. EL—L 4,__ G'A GW Ei- SHAIL't, APP0, J PRECAS-r TRAVELED WAYS WIiEREIN N-20 LOMWNG, ------- 3 AL�_ PIPE CONNECTIONS AND COKRE-f DIST. SHALL APPLY, MAVHOLE U�V`�R CONSTRUCTION TO aE *ATtEQ,1Tj6hj,% BOX 2. PROVY.)FE NLE" TEE OR BAFFLE WHEPPE SLeDiRf. OF rl 71 r' r#'7i INLET PIPE EXCEEDS 0�08FT./FT ORZ IN PUMPED SY-iTEM, L 7--—I - 1 1 FIRST TWO FEET OF P.113k OUT OF 005ST -- LAY T GENEPIA�_ NOTE'S-, 'T - AN VIEW BOX TO SE LAID LEVEL, j�-rik7 ' THIS PLAN 13 FOR DESIGN AND P" RE.NiOV E A FIL F CONSTRUCTION OF THE SEWAGE WAT f It LEVEL. _4 DISPOSAL rACILIT.Y O�� _21 ALL CONSTRUCTION METHODS AND 4c_ IV Film�c�,1�4 <7�Q� INLET TF �77 ATERIALS SHALL CONFORM TO MASS, 7L TITLE 5 AND LOCAL BOARD S 0YO F_j�z� OF HEALTH REGULATIONS, 0,WIN. 01JTL SEPTIC 1,r­­i 3 E E 0 DEPTH y rE �,N E'T A0, NOTE TA *Uk L i 'AL�_ PIPES LOCATED UNDER PA*VEMCNT OR TRAVEi_ED WAY SHALL BE %Zp SCHEDULE 40 OR EQUAL. T :�A= -4 L XWCTIA 80TY010 ON LEVEL StAkOCE 9ASE __UOTT�OM ON 4�0 '�7A"17 1�1­ =7 LEVEL_STA&L.E CROSS-SECTION PLAN V�EW CROSS-SEC'NON VIEW i-)t� Lx�A-;­jt! DATE- DATE: DA'E, DATE, CONSTRUCTION NOTES: 1114VLERT ELEVATIONS& TEST BY- TEST BY, TEST 8Y� TEST eY: WELL A _je_,7 - - 1� (� INVERT AT BUR-DINCI WITNESSED BY: WITNESSED BY, WITNESSED BY: LOCATION �f'N E SS ED e.Y INVE T AT SEP-11C TANK00 .4 7, 00 INVERT AT SEPTiC TANK(Out) AT PERC. RATE. PERC. RATE-, PERC, RATE,-. PERC, fRATE� LOT 16 1 1 0r 17 LOT 15 '�7 MINJINCH NVERT AT DIST, SOX(in) MINJINCH MIN j�411 fi INVERT AT D IST. BoXfoUt) P17- EDG� OF POND INVERT AT 'LEACH CHAMBER -14 3' 0 EL.= 4 5.0' WELL DATUM. L OCA T/ON BOT *rom OF LEACH CHAMBER 1�22 VERTICAL DATUM, MEAN SEA LEVEL U-S.G.S3, MArXiMUM GROUND 01A 4 WATER ELEVATION BENCHMARK USED: RIM OF CATCH BASIN ON HOLWAY DR. NEAR 7L/_M�/ T OF JGETATED WETLAND OBSERVED GROUNDWATER LOT 19 AS SHOWN ON PLAN BY BAYSIDE 'SURVEY CORP. BENCHMARK C.8ASIN ELEVATION DATED DECEMBER 8, 1980, PREPARED FOR JOHN J., RIM, 4 7.38' KENNEFICK. ELEV. 42.3 ( M PRI'VA TE VF .S. L. ) 401 WIDE DR t W awmaw L,- 44'5 HOL WAY C.BASIN I 0 PAVEMENT F J 7 ' EDGE _PIV4 .3 E N 870�_ 36 3 16 0.oc� Zt-i, 0 D E C"i N ��R 1 7 f::7 1 I L-A 14; -Y LINE- INFORMA771ON PROPER7 "'N FLOW: COMPILED FROM PLAN 3K. 249 PG. 107 DESI ANO OOE5 NOT REPRESENT AN __4_' .____8EDR00MSATLL G.P.13-ID A+r,.PM. L SURVEY ON THE GROUNi" OT 26 ACTUAL LOT 24 Lb 7 The C Group CA: REQUIRED SEP*fh'_'4' TANK- TOPOGRAPhlY RE/FFORIWED SY i / TRANSIT 8 57ADIA ME THOD. �Ij�ga GAL. SEPTIC TANK PROViDt-D' 2., GA LOTI, j i cli 5 2 0 011 151 cx: Ca e Cod Survey Consultants `)F LEACHING FACILRY REQUIRED: T F\ EXISTING DWELLING z �_ � ::7� "�_� 'k' , 4 PERC. RA7E-. DE,4� Ae, PROFESSIONAL LAND SURVEYOR DATE ------- 3261 Maii� APPROX. WELL :x� 0A Route 6 0 p ea 6 C ------ Bari'stable Viiiage tvIA 10263,1 617 362 81-3 ---------- ------------- EXI S TING _Q) APPROX. .:AZE OF LEACHNG FACLrrY PROVIDED: D WEL LYNG 1501 L SEPTIC TANK 14 EWAGE DISPOSAL 7 A, !!W,Tr�p/T PROXiSSIONAL tNGINEER-CIVIL DATE EL.= 4 9�9 SYSTDM DESIGN a I rb pox 7-S-z r4 j LOT 24 ...... HOLWAY DRIVE 4� k Jr IN TEST P,,',,"r U 49.5 c P1 Ak APPROX. LO %D L I\1 BARN 3 TABLE., LEACH PIT MASS . k,v ZONE : iRF SETBACK'S .* FRONT YA RD 30 S1 DE a REAR 15 M THOMAS F LECKSTRO ivy % 4* DkVfE., JANUARY 14, 1986 /�p. 0011 Z ............................1111�1��11��1111111111�111__ w . ............. S 870 36#-ZO UHFCK�, LOT 30 PLAN' VIEW C_ D RAVV'\4 R. CH. SCALE,, I" :z 20 �IEL" , D. J. B. LOT 28 LOT 29 UNDERGROUND UTILITIES WERE COMPLED FROM AVA ILA13LE Fii-E N­ DW Pi4NIES AND PUBLIC AGENCIES RECORD PLANS OF UTIL ITY Cr AND ARE APPROXIMATE ONLY. BEFORE DESIGN AND CCh%S0L`j"RUC- VA 10 20 40 (�;o F E-E T D'�,'V�Cl N G, 10 6 2 S ;7`_ 41 C "If __/ckc Tlq!t�ALL DIG SAFE I - 800 - 321Z-48 44 , JOB INO: 3. 1703 7