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HomeMy WebLinkAbout0139 LAKEVIEW DRIVE - Health 13 3 Lakeview Drive W. Barnstable A = 214 058001 R No. 4210 1/3 BLU n�al G- m 10°i0 a o 0 u Commonwealth of Massachusetts M P �/�MY-001 Title 5 Official Inspection oPm Subsurface:Sawage Disposal System Form Not far Voluntary Assessments 139 Lakeview Drive Centerville MA a°pe>,`Adaress Byron J Haseotes JR 1.39 Lakeview Drive Owner Ow ner's name information is Cenille MA 02632 7/15/2015 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 any way. Please see completeness checklist at the end of the form. tnportf Men en filing outut f A. Genera[ Information on the conputer, use only theitab 1. Inspector: ;# / /' key to move your. f ozq cursor-do not use the return Na ve of tispecter ,key. --h 30e Martins Ce3rrpany u SePcheck 27 Northside ter Company Address S. Dennjs, MA 1)2660 rffim Cityfrown State Zip Cade Telephone Nu rater License Number N©le. -e house duos 'at dal, f`c;d m q 4�oVe_ B. Certification � , . w c rx>' y nay o �c Cdns writ • 94Wj',r lr► -A.-4A is 3 eg— d'-r%. 7skA4 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�(33110 CMR 15.004 The system_ L�f'Passes ❑ Conditionally Passes © Fails El Needs Further Evaluation by the Local.Approving Authority o44z a S a inspector's Signatere Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner., and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address,how the system will perform in the future under the same or different conditions of use. Loj# V-5 15ns•3113 We 5Official InspeaSmFame Subsurface Sewege.Disposal System-Page t of 1,7 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sawa a Disposal System Farm Not for Voluntary Assessments 13 Lakeview Drive Centerville MA Pro�aadress Byron J Haseotes JR 139 Lakeview Drive Owner CWner's Name mformaWnis Centerville MA 02632 7/15/2015 required for every page. otyfrown — State Zip Code Date of hspectim B. Certification (oortt.) Inspection Summary:.Check A,B,C,D or,IE l a►wayscomplete all of Section D A) System Passes: l! 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 1`5-304 exist.Any.failure criteria not evaluated are indicated below. Comments: - fir!/l al✓S � ye.t tf d L✓�M-L B) System Conditionally Passes:. ❑ One or more system components as described in the"Conditional Pass"sec" n need to be replaced or repaired. Ibe system,upon completion of the replacement gki6pair, as approved by the Board of Health,will pass. Check the box for Ryes' `no"or"not determinedA(Y,_N, ND)for llowing statements. If'not determined,"please explain. The septic tank is metal and over 20 years old'or th eptic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltr or tank.failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. 'A metal septic tank will pass ins Lion if it is.structurally sound, not leaking and if a Certificate of Compliance indicating that the nk is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): ffins-3113 TMe501`11daf hispxSonFamc.SLbsWaw Sexage0isposal System-fte2of 17 f \ Commonwealth of Massachusetts MUMM Fills 5 Official Inspection For Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments 139 Lakeview Drive Centerville MA ° ""dares Byron 1 Haseotes JR 139 Lakeview Drive CW ner Ow ner's.Matra® infomation is Centerville MA 02632 7/15/2015 required for every i page. Cityr town State Zip Code Date of 61spection B. Certification (cola) Pump Chamber pumps/alarms not,operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cant.): ❑ Observation of sewage backup or breakout or high static water le n the distribution box.due to broken.or obstructed pipe(s)or due to a broken,settled or un distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced ❑ L7 N ❑ ND(Explain below): ❑ obstruction is removed Y ❑ N ❑ ND(Explain below): distribution box is leveled or rep ❑ Y ❑ N 1.1 ND(Explain below): 0 The system d pumping more than 4 times a year due to broken or obstructed pipe(s). The system will inspection if(with approval of the Board of Health): en pipe(s)are replaced 0 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('l)(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 50feet of a bordering vegetated wetiand or a salt marsh tins•W13 Tt6e5Oftd InspectmFam SubsWmeSevogeDispasaf System-Page 3gf17 Commonwealth.of Massachusetts Title 5 Official Inspection berm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 139 Lakeview Drive Centerville MA Property Address Byron J Haseotes JR 139 Lakeview Drive Ow nw ON ne's tame information is Centerville MA 02632 7/15/2015 required for every Page- City/Town State Zip Code Date of inspection B. Certification (coat) 2. System will fall unlessthe Board of Health(and Public Water Supjftr,if any) determines that the system is functioning in a manner that pro the public health, safety and environment; El The system has a septic tank and soil absorption sy (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a su a water supply. ❑ The systems has aseptic tank and SAS and th AS is within a Zone 1 of a public water supply ❑ The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. The system has:a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water suppi 1". Method used to determine dis ce: "*This system passes if well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria.Indic es absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp ,provided that no other failure criteda are triggered.A copy of the analysis rnust be attached to th' -farm. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool E] Liquid depth in cesspool is less than 6"below invert or available volume is less than%day Sow tars-3113 We5Official Aspecltm.Form SL6saface Setwge0sp� System-Page 4of 17 Commonweaffh of Massachusetts g ME almna Fills 5 Official Dnspection Form U1WSubsurface Sewage Disposal System Form -Not forVoluntary Assessments 139 Lakeview Drive Centerville MA ProPerty.Addrem Byron J Haseotes JR 139 Lakeview Drive °xrw Centerville MA 02632 7/15/2015 infornmfim is required for every page. Qtyrrown state Tip Code Date of Inspection B. Certification (c onL) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s.).(dumber 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. I ❑ [A 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 wateranalysi% performed at 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.] El The system is a cesspool serving a facility with a design flow of2000gpd- 10,000gpd. The system falls 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 most indicate either"yes"or"no"to of the following, in addition to the questions in.Section D. Yes No El ❑ the system is w' 400 feet of a surface drinking water supply ❑ ❑ the sys is within 200 feet of a tributary to a surface drinking water supply system is located in a nitrogen.sensitive area(interim Wellhead Protection Area— IWPA)or a mapped Zone It of a public water supply well If you have a wered"yes to any question in Section E the system is considered a significant threat, or arts we 'fires"in Section D above the large system has failed.The owner or operator of any large syst nsidered a significant threat under Section E or.failed under Section D shall upgrade the syst n accotdnce.with 310 CMR 15.304. The system owner should contact the appropriate regional.office of the Department. t5irs•3113 TdteSOfficW ftspeptimFora SLbsisfaw SEiwQeOispasd System--Page Sof17 Commonwealth of Massachusetts Fills 5 Official Inspection Form Subsurface Sewa a Dtsposat sr stem Form-Not.for Voluntary Assessments 13� La evlewyDrive Centerville MA Property Address Byron J Haseotes JR 139 Lakeview Drive aanr onfners nianfe information is Centerville MA 02632 7/15/2015 . required for every page- City/Town State Zip Code Date of Inspection C. Checklist . Check Ef the following have been done:You must indicate"yes'or"no"as to each of the following. Yes No in/ El Pumping information was provided by the owner,occupant, or.Board of Health ❑ (td Were any of the system components pumped out in the previous two weeks? ((d' El Has the system received normal flows in the previous,two week period? 2/ 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 bretak�out? L7 ❑ Were all system components,�nig the SAS, located on site? tsd' ❑ Were the septic tank manholes uncovers opened, and the interior of the.tank inspected for the condition of the baffles or toes, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? gg,,� ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface.sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been.determined based on: ( ❑ Existing information. For example,a plan at the Board of Health. ❑ Determined in the field (If any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual). DESIGN flow based on 31.0 CMR 15.203(for example: 110 gpd x#of bedrooms): Lf Zim.31f3 rftSOfft rkopecrimFa SubsurfaceSavgge Disposal SyMem-Page 6of17 Commonwealth of Massachuse#s Titre 5 Official Inspection Form Subsurface Sewa a Disposal System Farm-Not for Voluntary Assessments 139 Lakeview Drive Centerville MA Prop"Addrem Byron J Haseotes JR 139 Lakeview Drive Ow rw ON Name information is Centerville MA 02632 7/15/20,15 required for every page: Cityfrown State Zap Code Date of Inspectim D. System Information Description: t /) I ( Gt ✓� d s fi� a Number of current residents: Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes U� No information in this report.) Laundry system inspected? A br- ❑ Yes ❑ No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: t�" : 2g�aafl • Age s AI "I"IrN t P11-1k Sump pump? ❑ Yes No. Last date of occupancy: .. / we Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CUR 15.203): Gallo y(gpd) Basis of design flow{seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank ent? ❑ Yes ❑ No Non-sanitary wast charged to the Title 5 system? [] Yes ❑ No Water.meter readings, if available: GSrs•3!13 'ndeSOffMalI spw5onFow SubsufamSeuegeflisposal Sgstem•Page.?of 17 Commonwealth of Massachusetts Fills 5 Official Inspection Dorm Subsurface Sews a Disposal System Form_Not for Voluntary Assessments 13�3 Lakeview Drive Centerville MA RopertyAddress Byrom J Haseotes JR 139 Lakeview Drive Ox Wore (1�vners Narte Centerville MA 02632 7/15/2015 information is required for every page. C ityrrawn State Zip Code Date of k�pection D. System Information (cunt) Last date of occupancy/use: Date Other(describe below): General Information ✓� Pumping Records: ` _ ' Source of information: - Was system pumped as part of the inspection? ❑ Yes No If yes, volume-pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: VSeptic tank, distribution box, soil absorption system ❑ Single cesspool r Overflow cesspool El Privy 0 Shared system(yes or no) (if yes, attach previous inspection records, if any) 11 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 VA system by system operator under contract ❑. Tight tank, Attach a copy of the DEP approval. ❑ Other(describe): t5ns-V13 Title S Officid I spectton Form Subsurface Same Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Supbsurface.Sewage Disposal System Form-Not for Voluntary Assessments 139 Lakeview Drive Centerville MA 1401ertyAddress Byron 1 Haseotes IR 13.9 Lakeview Drive onner Ovnees Name ra irdontion is Centerville MA 02632 7/15/2015 required for every page. Cttyfrown state Zip Code Dale of inspecton D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ YesX No Buitc.ing Sewer(locate an site plant' Depth below grade: feet Material of construction: El cast iron 40 PVC ❑ other(explain): - Distance,from private water supply well or suction line: ! feet Comments(on.condition of joints,venting, evidence-of leakage,etc.r Septic Tank(locate on site plan): j Depth below grade: feet Material of construction: 0-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) 0 Yes ❑ No Dimensions: /O S�__ ;� : Sludge depth: r„ t 'L t l l h (P / t5ns-3(13 Ta_-5 oractm ltspwtm•Fmm SLhurra oe seumge t)mPw t system•Page W 17 Cammanwealth of Massachusetts Title 5 Official Officiall Inspection Form Subsurface Sewn Disposal Systern Form-Not for Voluntary Assessments 13�a Lakeview Drive Centerville MA Property Address Byron;! Haseotes A 139 Lakeview Drive Owner Ownees Name information is Centerville. MA 02632 7/15/2015 required for every --- --- -- page. Myrrown State Zip Code We of hspectim D. System Information (cunt.) Septic Tank(cunt.) Z Distance from top of sludge to bottom of outlet tee or baffle <f `t e- 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 How were dimensions determined? C'v►.e .P� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, eta): Pv- 12v& O✓2Y.P Tr -P �9, 3D ceile2s ha Gt} rJ) �f Grease Trap(locate on site plan): Depth:below grade: feet Material of construction_ concrete ❑ metal X[Ole s ❑ polyethylene 0 other(explain): DimensioZn Scum thi Distance tlet tee or baffle Distancem of outlet tee or baffle Date of last pumping: Data t5ms•3M3 Td[e5gr5cfarInspacbmForm:.SubuWace Savage Disposal=Slalom-Page 10o 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal Systern Form -Not for Voluntary Assessments 13 Lakeview Drive Centerville MA RopertgAddress Byron 1 Haseotes 1R 139 Lakeview Drive Ow omatlon is 0-4 'S lame Centerville MA 02632 7/15/2015 required for every page. Cityffown state Zip Code Dde of lnsWWn D. System Information (conQ Comments (on pumping recommendations, inlet and outlet tee or a condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, Tight or Holding Tank(tank must be pumped at time of.inspection)(locate on site plan): Depth below grade_ Material of construction_ ❑ concrete ❑ metal ❑fib lass ❑ polyethylene ❑ other(explain): Dimensions: Capacity gallons Design Flow: �nsper day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in woridng order ❑ Yes ❑ No Date of last pumping; Date Comments (conditi of alarm and Boat switches, etc.): *Attach copy of current pumping contract(required Is copy attached? ❑ Yes ❑ No ems•3113 Title5oMdW kspecdonFo=Sulswfa SewageDispoad Sim-Page 11 of 17 Commonwealth of Massachusetts Fills 5 Official Inspection Form Subsurface Sewa Disposal System Form-Plot for Voluntary Assessments 13�Lakevew Drive Centerville MA Y RropmVAddrem Byron J Haseotes JR 139 Lakeview Drive caner aYners Nam inforrrration is Centerville MA 02632 7/15/2015 required for every page. cuyrrown state Zip Code Date of rnspectbn D. System information (cont.) Distribution Box (f present must be opened)(locate on site plan): Depth of liquid"level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of bo)c, etc.):. t t P 121 ge s o s 0MP lJ�4t�q tA) A-tJ a Ste t,- r- 1-0 yJ VJ t . Pump Chamber(locate on site plan): Pumps'in working order. E es ❑ No* Alarms in working order. 0 Yes D Not Comments(note condition of pump chamber,conditio pumps and appurtenances, etc.): */located, re not in working order,system is a.conditional pass. Sem(SAS)(locate on site plan,excavation not required): tf notplain why: tyre 3M3 Ti6eMrkisl IrepecionForm Subsurface SeviVeDisposal S}stem•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal System Form-Not for Voluntary Assessments 13F Lakeview Drive Centerville MA PropertyAddrms 6yCor11 NaseQtes JR 139 Lakeview drive Ow ner aiyriersNarre ! q� 02632 '�y �y ' inforrredon i.S Centerville IYEH: kfL J / �2 �5 required for every page Cityrrown State Zip,Gode Date of hispecfbn D. System Information (coat.) Type: teaching.pits number leachin chambers number. 3 Zo �Z' 9 t C] leaching galleries number 0 leac t ing;trenches number, length: El leaching fields number,dimensions: [] overflow cesspool number: Q innavativelalternative system Type/name of.technology: Comments (note condition of soil,signs of hydraulic failure,level of pondipg,damp soil, condition of vegetation, etc,.): -P ! e4kj S C Ito Pr a r A v Pss Cesspools(cesspool must.be pumped as part of inspection)(locate on 'e plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of`const tiort - - lndication o roundwater inifow ❑ Yes 0 No tWo-3tt 3 Tipe5orflclel gspmUmFmreSubsWace 8wmgeDi5pasW,5PWm.Page 13 or 17 I Commonwealth of'Massachuseft Fails 5 Official Inspection Form Subsurface 5ewa a Disposal System Fwm-Not for Voluntary Assessments 13T Lakeview Drive Centerville. MA a-opert,nddrms Byron J Haseotes JR 139 Lakeview Drive OW nor °"'"ers"a"'s information is Centerville MA 02632 7/15/2015 inf required for every page- C ityfrown State Zip Code bate of inspection D. System Information (corn_) Comments (note condition of soil, signs of hydraulic fatEure, level of ponding,condition of vegetation, etc.):. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition o/signis raulic failyre, level of ponding,condition.of vegetation, etc.): tina.•3M3 TWeSCMW hispectian Fortrc Subswfaee SewageDisposaf System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form Not.for Voluntary Assessments 139 Lakeview Drive feel MA RopertfAddress Byron I Haseotes A 139 Lakeview Drive Ow ner owner's Name information is G@R'-E� VJ j MA 02632. 7/15/2015 requtredfor every. S page. City/Town fate Zip Oxle Date of Inspection D. System information (conL) Sketch Cif 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 di public water supply enters the budding. Check one of the boxes below. hand-sketch in the area below drawing attached separately f�L s= t 2 A4 f�.-. g 1 l q s . 25 I✓V { b✓ I?k F a • i e 15m•-Y,3 T*e5OfftIMImpeclonFam.Sub WaceSavageDispasal_Syslem•rage-15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form--Not for Vol untary Assessments 139 Lakeview Drive Centerville MA Rop"Address Byron J Haseotes JR 139 Lakeview Drive aNner °nr"WS Nam information 15 Centerville MA 02632 7/.15/2015 required for every page. City/Town State Zip Code Dabs of tlspection D. System Information (cont.) Site Exam: Cd'Check Slope GP Surface water L9',,C//heckc cellar C7/Shaliow wells Estimated depth to high ground water: feet Please indicate all methods used to detennirie the high ground water elevation: ❑ Obtained from system design plans on.record If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 160 feet of SAS) ❑ Checked with local Board of Health explain: ❑ Chocked with local excavators, installers-(attach documentation) Accessed USGS database-explain: S 0-9 TZ RIO _ �ays �I� um. &I S Ail X-id K124 'C rp j�1 Z, You must describe how you established the high round water elevation: I(. M/Pc AZt„s-.e �Ybde�e lktva 7. 01 Before filing this Inspection Report, please see Report Completeness Checidkst on next page. ins.3113 TWe5OMdW trepwfrcnFor=Subsurface SewageMsposal System-Page 16 d 17 Commonwealth of Massachusetts Ville 5 official Inspeclion Foy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 139 Lakeview Drive Centerville MA Properly Address Byron J Haseotes JR 1.39 Lakeview Drive Owner Owner's Name Wonnation is Centerville MA 02632 7/15/2015 requfred:for every - page. Cltyfrown State Zip Code Date of Inspection E. Report Completeness Checklist F(Inspeefion Summary: A,B, C, D,or E checked L' Inspection Summary D(System.Failure Criteria Applicable to All Systems)completed JSystem Information—Estimated depth to high groundwater ® Sketch.of Swage Disposal System either drawn on page 15 or attached in separate file t5�.3113 MR950Ekckd tmpec6onFo=SLbsWace SWAVeMpMW SWWM-Page 17 d 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 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 any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name � P.O.Box 763 Company Address Centerville Ma. 02632 few City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority F A� ,/ i:c'x� 8/20/2009 r In pe ors Ignat re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use . at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09108 Title 5 Official Inspection Form:Subsurface Se' ge Disposal System•Page 1 of 17 e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): M t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool h ❑ ® 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 %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 ®fficial Inspection dorm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 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 i e s . Number of times pumped: PP ( ) P P ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® ' Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large M system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2007:364,000 9 ( Y 9 (gp )) 2008:99,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 8/20/2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every page. 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. i ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 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: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 3' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 139 Lakeview Dr. M Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i� Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is CentervilleMa. 02632 8/20/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has three outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection 0=orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Chambers had 6" of water on bottom at time of inspection.Stain line observed 16" below invert. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name . information is required for Centerville Ma. 02632 8/20/2009 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 �6 y®f O t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LC 20'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: 2003 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) .® Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 139 Lakeview Dr. Property Address Eric Boguniecki Owner Owner's Name information is required for Centerville Ma. 02632 8/20/2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWT�QF BARN TABLEL LOCATION / : SEWAGE # VILLAGE ` I-Ef l ASSESSOR'S.MAP & LOT -U iINSTALLER'S NAME&PHONE NO. C'0 h,.SEPTIC TANK CAPACITY .K LEACHING FACILITY: (type) (size) " NO.OF BEDROOMS BUILDER OR OWNER /' �( / 67 00-1 PERMITDATE:�r ` :dfl^ COMPLIANCE DATE: ti Separation Distance Between the: s Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /14� Feet Private Water Supply Well and Leaching Facility` (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching acility(If an wetlands exist within 300 feet of leachi acility) Feet Furnished by - t44-6 6 19- 16 'l '� ram' � ! � '• ' � � f". No. X2 ' THE COMMONWEALTH OF ASSACHUSETTS Entered i mputer: Yes PUBLIC HEALTH DIVISION -TOWN OF B NSTABLE, MASS SETTS Zipprication for Migogal *pztem Cott.5truction Permit Application for a Permit to Construct(�)Repair( .)Upgrade( )Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No. 4d 1f_YVy Owner's Name,AddreS s and el.No. / ?6 7 (o z9 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Z-r r.-y �/ C �cr J --/1 y�-c -G 3 C U i✓ 3 `Z Type of Building: Dwelling No.of Bedrooms Lot Size��sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 -3 CS gallons per day. Calculated daily flow 11 c,X � gallons. Plan Date ,[r/.9 Number of sheets / Revision Date Title Size of Septic Tank G 4 Type of S.A.S. 3 T T...� Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Tile 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t is Board%)filth. Signed = Date /_C Application Approved by Date h-- Application Disapproved for the following reasons Permit No. Date Issued /l—l—7-0- O 4_11"N6 No. � rN �AB F too NWEALTHOFUSETS- Entered omputer i UBLIC'HEALTH DIVISION TOWN OF ES MAS AEHUSETTS'`{' Zippfication`ffor MigpooaY Opoteni Couttruction permit Application for a Permit to Construct(X)Repair( pUpgrade( )Abandon( j ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and el.No. 1 C1 2 �117 " Assessor's Map/Parcel a Z jI✓� (�, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Irt Type of Building: ter/ Dwelling No.of Bedrooms Lot Size 7C sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ; Other Fixtures 1 _ Design Flow V gallons per day. Calculated daily flow �/G -� gallons. Plan Date /U/ 9 9 Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. ., Description of Soil ' Nature of`Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure:he construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Titre 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by,tfiis Board o H lth. Signed Date / 'C Application Approved by 4LD Date Application Disapproved for the following reasons Permit No. Date Issued /I- ��2U"t17j1 k' --------- --------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage isposal System Constructed( Re re (., Upgraded( ) Abandoned( )by ( �t/�r9 / at V1 r w V f< bee co tructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. W date Installer /� / ft/F ("!r urn / Designer FIf t The issuance of this enit'hall not be construed as a guarantee that the s wunct n as desi ned. Date f f�e�1)k,[, Inspector 1 ---------- ----------------------------- No, Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mio papal 6potem Congtruction Permit Permission is hereby grants to Construct(�<Repair( )Upgrade( )A.andon( ) System located at 7 ,'/ 4try and as described in the above Applicadofi for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this-permit. Date: Approved by � �'` I TOWN�QF BARN TABLE LOCATION ` SEWAGE # VILLAGE �a I � /A '/ �5 ASSESSOR'S MAP & LOT INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ' 7'�- (size) NO. OF BEDROOMS BUILDER OR OWNER -9 �" (7-J PERMTTDATE: C ' .4�_COMPLIANCE DATE: V Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching acility(If an wetlands exist within 300 feet of leachi acility) Feet Furnished by AI r� P-16 a rm pt Fir -T IF HT 11 1 [IE ELA -Sy-Y1'1�M A,d Fki�F�..OW0. E.-'.,_i c7 h��A-fly°".=.__l�:��xt� DRAWING NUM13ER IN It.. ..J. 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