HomeMy WebLinkAbout0241 PLUM STREET - Health 241_Plum Street G
West Barns able
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Commonwealth of Massachusetts ( l �
w Title 5 Official Inspection Form �s °�
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
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 A. General Information
filling out forms
on the computer, jif
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use
key the return Name of Inspector
CD
S.M.Jones Title V Septic Inspection
ICI Company Name ^== ,
74 Beldan Ln.
r, M
Centerville Ma — 02632
City/Town State Zip Code.
774-248-4850 smjonestitle5@gmail.com SI4522
Telephone Number License Number C73
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0-
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
7
,n.
3/22/2014
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
11q11ejPage1of17 t5ins•3/13 Title 5 Official Inspection ubsurfaceSewage Disposal Syst
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 dwelling located at 241 Plum St west Barnstable is served by a Title V septic system consisting
of a 1500 gallon septic tank, distribution box and 2 1000 gallon precast leaching pits. The system was
found to be in proper working condition at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
241 (Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Lmn. /13 Title 5 Offidal Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. CitylTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4+ Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1098 gpd
provided
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 241 (Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes Z No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d well
9 ( Y 9 (gP ))� I
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: vacant/unknown
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. CitylTown 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.
❑ Other(describe):
t5ins•3/13 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
241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
D. 'System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system 1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 1.5
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 gallons
Sludge depth:
6"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
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
3"
Scum thickness
3"
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
10"
How were dimensions determined? opened covers, took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank should be cleaned soon and again every 2 years for proper maintenance. water level was even
with outlet, tank was not leaking and was 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
Lt5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was in good condition, no rot, water level was even with outlet invert.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: WOW gals
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching,fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pits were video inspected and found to be dry with no sign of past hydraulic overloading. Leach
pits are located in the stone driveway and are H2O loading with 2'of stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Ma
ssachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
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
A � + 3� � 33: vck Z
3
38
s
O
i
l5ins-3113 T Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every west Barnstable Ma 02668 3/22/2014
page. Cityrrown 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: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
El Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
241 Plum St.
Property Address
CRIVELLARO, SHARON E
Owner Owner's Name
information is required for every West Barnstable Ma 02668 3/22/2014
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
j
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
J
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 241 Plum Street
West Barnstable
Owner's Name: Don Spring r
Owner's Address:
Date of Inspection: 8/17/2006 v ��
Name of Inspector: (please print) Patrick T. Sullivan
Company Name: Ready Rooter
Mailing Address: P.O.Box 371
Sandwich,MA 02563
Telephone Number: (508)888-6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails >•..�
Inspector's Signature: l� _ Date: 01
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of He lth or 4n
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the .
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments -
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
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"Conditio 1 Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair s approved by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the for a following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or a septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank s approved by the Board of Health.
*A metal septic tank will pass inspection if it is struc ally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is ailable.
ND explain:
Observation of sewage backup or bre out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settle or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required purr ng more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approva of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation y the Board of Health in order to determine if the system
is failing to protect public health,safety or the enviro ent.
1. System will pass unless Board of Health termines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner w ich will protect public health,safety and the environment:
—Cesspool or privy is within 50 fee of a surface water
Cesspool or privy is within 50 f t of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_The system has a septic tank and soil absorption syste (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supp
The system has a septic tank and SAS and the S S is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and th SAS is within 50 feet of a private water supply well.
_The system has a septic tank and SASVand he SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method useetermine distance
"This system passes if the well water ana performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indi ates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrat nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the alysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
�[ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(�(Yes/No)The system fails. I have determined that one or more of the above 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 sery a facility with a design flow of 10,000 gpd to 15,000
gpd. .
You must indicate either"yes"or"no"to each of th following:
(The following criteria apply to large systems in a ition to the criteria above)
yes no
the system is within 400 feet of a su ace drinking water supply
_the system is within 200 feet of ibutary to a surface drinking water supply
the system is located in a nitr gen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water su ply well
If you have answered"yes"to any uestion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the lar system has failed.The owner or operator of any large system considered a
significant threat under Section or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner sh Id contact the appropriate regional office of the Department.
j
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
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?
-Z Have large volumes of water been introduced to the system recently or as part of this inspection?
-Z _ 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 than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_ Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): l� p ,
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):,QL�i[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):L,
Water meter readings,if available(last 2 years usage
Sump Pump(yes or no): &D,=)
Last date of occupancy: C c--.%� w
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sq. ft.e _
Grease trap present(yes or no):_
Industrial waste holding tank present(y s or no):_
Non-sanitary waste discharged to the itle 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: _I�e r•��,��pQ� �,� �
Was system pumped as part of the inspection(yes or no): Yc--5
If yes,volume pumped: allons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_j,!!0"S-eptic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
_T Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
T Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known) J �
and
d source of information: (' l
f l/I` 7 / a AC C or'
Were sewage odors detected when arriving at the site(yes or no):��
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
BUILDING SEWER(locate on site plan)
Depth below grade: *3 3
Materials of construction:_cast iron�0 PVC other(explain):
Distance from private water supply well or suction line: I SIC)
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: Q 41`
Material of construction:_Zconcrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
t C
Dimensions:
Sludge depth: S "
Distance from the top of sludge to bottom of outlet tee or baffle:
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: lel,'
How were dimensions determined:—7. -t v yA
Comments(on pumping recommendatioils, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_me 1_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to to/of
ee or baffle:
Distance from bottom of scum outlet tee or baffle:
Date of last pumping:
Comments(on pumping recominlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidege,etc.):
1,
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
TIGHT or HOLDING TANK: (tank must be ped 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: gallo /day
Alarm present(yes or no):
Alarm level: Alarm in wo ing order(yes or no):
Date of last pumping:
Comments(condition of alarm d float switches,etc.):
DISTRIBUTION BOX:__Z, (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: C)„
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Q)' f �c�� C9�Ttri�S z.✓/ Co c�a� �r�'�c� . acl�'� �
(,va., 'gar,�,�; 6 '
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chambe condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
T leaching pits,number: k co�� o� t g7j'* .'e' �s►c�-�..
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
r. Caws... N\gtJai
CESSPOOLS: (cesspool must be pumped as pa 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 r no):
Comments(note condition of soil,s' _s 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/f hydraulic failure,level of ponding,condition of vegetation,etc.):
I
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.
I �
1
I t
............ O O
� � O
vv
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 241 Plum Street
West Barnstable
Owner: Don Spring
Date of Inspection: 8/17/2006
SITE EXAM
Slope f
Surface water
Check cellar
Shallow wells
Estimated depth to ground water �> L4 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_V�Obtained from system design plans on record—If checked,date of design plan reviewed: C.
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with the 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:
en
WILLIAM LIEBERMAN
REGISTERED PROFESSIONAL ENGINEER
LICENSED REAL ESTATE BROKER
235 TIMBER LANE(MARSTONS MILLS)
W. BARNSTABLE, MA 0266E
1617)426-2592
November 13, 1986
Torun of Barnstable
Board of Health
Town mall
Hyannis, Ma. 02601
Lot 10 Plum St .
W. Barnstable, Ma.
Gentlemen:
On November 13, 1986 I inspected the septic system
being installed 6n the referenced lot in accordance with the
Site and Sewage Plan revised on 8-5-86 and find the install-
ation to be satisfactory.
A 1500 gallon standard septic tank had been install-
ed more than 10 feet from the building, a distribution box and
two H2O Loading Leaching Pits with two feet of stone. The
center of the leaching pits were approximately 25' from the
building and approximately 28' center to center. Piping had
been installed from the house to the septic tank from the septic
to the distribution box, and from the distribution box to the
first pit .
i
Very truly yours,
William ieberman RIPE
WL:el
cc Barnstable Building Co. .
OF�'��9
� bly4c\4
<.I`' UEBERiV1AM c
TOWN OF BARNSTABLE V
LOCATION a "t t 1P(y Y\N 1ST, SEWAGE#
LLAGE A,r^gidStk-P ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. (f v,,k ® .
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type) L.c kc 1,�, ,m y� (size) v x
NO. OF BEDROOMS .3 � �'�,,� c(
OWNER N Awl A v��
PERMIT DATE: /// g a I COMPLIANCE DATE:
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) CC) r Feet
Edge of Wetland and Leaching Facility(If any wetlands exist _
within 300 feet of leaching facility) ���� Feet
FURNISHED BY
r?�J7 fc�G 1
i ►{`3 44
3
Cc,
c d ��, O O Li
J e O
S
.ASSESsGFt'S MAP NO. 17� PARCEL
-to CAT IOW-,i{j SEWAGE PERMIT NO.
' -fit`
LLAGE
_ /�a,�s fret/-e.:•
INSTALLER'S NAME i ADDRESS . . .
c ai-1
BUILDER OR OWNER
L—a c
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
s K,
� .
.�
,•
.�— — `"�
�� l
� � �
1. �� �'�,
i / •\�
:r /
fi �
/ / �
� � �
,/ / M
` � o
/ ✓ e�
� \ �`� .. �
:� r ,.� `^
. /% � �'
�� r � _
n 1 THE COMMONWEALTH OF MASSACHUSETTS
°( BOAR® OF HEALTH
Ow AJ . . ..........
ApplirFatiou for Disposal Works Tomitrurtiou rnmit
Application is hereby made for a Permit to Construct ()(0 or Repair ( ) an Individual Sewage Disposal
System at:
L.oT .A �v2 n�sx 3 _
.............. - ............... ... ! .- ----.................... ............-----
- ---------
- / Locatio -Ad ess or Lot No.
Y .� .........' .Y�% .............. wok , --------------C�t�--:-,z �z 5'.:
Owner _ Address
w ....._kAA !-a_0
Owner .0................ C
Installer Address yl A e�
Type of Building Size Lot.....4 W.........Sq. feet
Dwelling�o. of Bedrooms.__..._................................Expansion Attic (gyp) Garbage Grinder )
Other—T e of Building No. of persons.......................: Showers — Cafeteria
Other fixtures ................................. ......
W Design Flow...........................................gallons per person per day. Total daily flow....... .....................gallons.
. a
WSeptic Tank—Liquid capacity..J.�aC?.gallons Length................ Width................ Diameter---------------- Depth....�k---A Lr
x Disposal Trench—No. .................... Width......_........_._.. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------- Diameter......J:n_1...... Deptli below inlet.....�.�........ Total leaching area..;KR,_-.s . ft.
Z Other Distribution box (X) Dosing tank i ) /a%0�AL��A7
~' Percolation Test Results Performed by...... t._._..! �?'�@' .a ......................... Date.-(/ lf. ✓� j..��1
Test Pit No. 1......2r:--minutes per inch Depth of Test Pit..... 2.`...... Depth to ground water_Z 3...............
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit....
......_..._.... Depth to ground water..?...................
a ........................................................... ............... ..---------------•-----------•--..............•----••-•...........----•---••-
O of Soil Description 0�_. .�..... .....' .'"---•�v�r..ri1� SIN v� --
x p n
U Z -^/z.`------� .... ..�-n��.............®!`. ...!..�oti,c" �. E.. -S -!!!`� �
-- ----------
W -----------------------------•----------•--•---•----•------•--------------------------....--••-•---•---••------•------------•--------•-•------------•-••-----•-•---------------------•---•---•-------•--
UNature of Repairs or Alterations—Answer when applicable................................................................................................
------------------------------------------------•-----------------------------------...............---•-•----...---------------------------------------•----------------------------•---........---••---
Agreement:
:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1' 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ssue b t e o of health." Q
Signed. /. ......••. . • -• ...... Z... 1.4 ' .-.
Application Approved BY............................................................ ....... '-
Da
Application Disapproved for the following reasons:.................. ...........................................................................................
............................•••-•-----•--•----••--...----•--•------•---•------•-..........•---------•-•--••--•--•••--•----••-----•••------•-----••••----•••••••-•-•••--------•-•---------•-•--•-......_.
Date
PermitNo......................................................... Issued.......................................................
Date
No................_. F>�s............7. .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
2-Il1STA.'�C E:.-®F�►.?-v...� �. .... . ..............................................
Appliration for Disposal Vorkg Tomitrttrtion Frrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
o-r # I b u! t......��?.�. W IS/�✓Z tiJST/-\3CrG
- _-- ----...... ----•.... ...........••-••-•••--•-----......._._..------_..._
Location-Address or Lot No. -• •-•-
................. f. ._ ...._... ..L ._d`_..:.._. ................. /^f---- ._...._.__..................._. _ ...... .......__.:!_.._........................
Owner Address �•
Installer ...-C.. _ __ q,'/
- Address ���!�� �1
Type of Building Size Lot....4A9 ..........S feet
a Dwelling—No. of Bedrooms.___.____4..•-.-.---.--•---•___.____..__Expansion Attic ,flo) Garbage Grinder V )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures .
W Design Flow.................. .5_..............gallons per person per day. Total daily flow......`f_ . ......................gallons.
* Septic Tank—Liquid capacity_1C4U_gallons Length................ Width................ Diameter................ Depth__q-'_L'4'
Disposal Trench—No_____________________ Width.................... Total Length................_____ Total leaching area....................sq. ft.
Seepage Pit No.......... Diameter._.___Q.......... Depth below inlet____ ........___ Total leaching area_s3 __.__.s . ft.
Z` Other Distribution box (x) Dosing tank ( ) ++__ 1&946 4A�l Av
aPercolation Test Results Performed by...... !_ -_!.e_tJ P_va+�_u i✓_•�______________________ Date_tM?4 Z�L_ul___�`Z
Test Pit No. 1----- ----• �-----•-
minutes per inch Depth of Test Pit_.____ Depth'to ground water_-4.3___.............
Lt. Test Pit No. 2................minutes per inch Depth of Test Pit.../Z.......... Depth to ground water.Z 31_____-__.____
P4 .................----------•-----•---•--•---•---•-_--••• -..................................... ..............
Description of Soil.......Q_.'.:.. .._-----f r1,� �' `�3-J�--o/�-" j f'G'r�i� s` �N` � ��� =
x ---•--------------------------------�-- ---- -- r t? 1� n�1�---...C.�4'!/ _.. {�tic� Sa�i� f�iv� s�......_
W •-- t - ---------------
x ---------------------------------•------------...--..-----------------------------•---...-------------------•--------------------------•-----------•---------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
•----------••--•-------------------•------------------------------••---------------•-•------------------------...._..••••.......----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.-
Signed............... t'e .._
r Dat
Application Approved By-•---•----••-------•---••--••--•-•-------------••--- - Z n e
Application Disapproved for the following reasons:................
----- --------•------------------------------•-------------------------------••--••-----•-
.............•--•--•••••-•--••••----..__...-----•--••--••-•-••-•-•---•-•--------•-••-...--•-•-------•-••----••---•--•---•-------•-••-•-•----•-------••--•----------•------------•----•---•-----------•--
' Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
U.uJ.. ..................O F........ ....... STA! C a;
...... .... ...................... ........................_.............._...
Trr#ifiratr of Tontpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X) or Repaired ( )
by 1- ::. ? .. .._.._..-J!:... a- ••-•-'----- ••-••---••-•••----••--••-•---•----------------•-._......................•---------...----•--•--
- ��Igstall
at.-•-•-•-•--•••-- - ------ (.0•----------• !C wv�----- ! -W :> 'Q i
- • - --•--...---•---•--•---•-•-•••--•---•---•......-••--•-------•-
has been installed in accordance with the provisions of TI-TLE r5 pf The State Sanitary Code as de cribed in the
application for Disposal Works Construction Permit _�__..�___________ dated-..... . _Q,1_G.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANT E THAT THE
SYSTEM WILL FUNCTION/ SATISFACTORY.
p DATE `/ G--4' ... ------------------------------------ Inspector--
o_�4— THE COMMONWEALTH OF MASSACHUSETTS f
t
BOAR OF "4E-FA!IhN H'_NGINEER MUST
SUPEr.............................OF .._... _ ._ - C .:_. S
No..._._ QRD °1�lrri W A*S INSTALLED° iW WiR E!Nlr•-------
��.� ANCF TQ IN STRICT ......
Disposal Work.5 %I.Vontrttrthan pff-mit
Permission is hereby granted....... f '"
rt {
to Construct �' or Repair ( ) an Indiyidual Sewage�Disposal Syste�
at No...............
.........�-•n -•-•...--=-L �'' -- -_----U'-'-------��.'4_l.� v �'1
-- - r• ,[[��
as shown on the application for Disposal Works Construction Permit N08{:"_ t __ Dated.... -V-C?
1 l - 4---- ' ---------------------------•--------
DATE_
................•---•-•--•---•----•---...-----.._....------•----•••-- Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
Department of Environmental Management/Division of Water Resources
WATER WELL COMPLETION REPORT
t WELL LOCATION
Address 11'7 /!� Pl I,► , ,S-f"
City/Town G] .bb rn, b 1 P.
G.S.Quadrangle Map
Grid Location (� I �1..,-�+
Owner rJ sDf ! ", lw a, S�/t l'� d
Address Ph CSCO 0.'� (f.J
/ELL USE CONSOLIDATED WELL
Domestic® Public ❑ Industrial ❑
Type of Water-bearing Rock
Other x `
Wateribearing Zones
Method Drilled U f" 1) From To
O ) 2) From To
Date Drilled O ' n ! 3) From To
4) From To
CASING / Depth to Bedrock
Length �Q Diameter ''Y r�
Type <-fyI*C. UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surface 0 Sand: fige❑ medium[]coarse
Date measured ��an—91. Gravel: fine ❑ medium❑ coarse❑
Screen:
GRAVEL PACK WELL Yes No Q r Slog/0 length �� from to
❑
Split Screen(or 2nd screen)
WATER QUALITY TESTS MADE Slog length from to
Chemical�21 Biological ❑ Depth To Bedrock
PUMP TEST
Drawdown feet after pumping days = -hours at r0 6 GPM.
How rrleasured f-,or►' 4,f, Recovery 'feet after hours.
V.M CY
LOG of FORMATIONS COMM NTS: (On well or water) �.
Materials From To
0
m e li 01
C.
DRILLER H
Firm �P� Ml ��)pl/ �r� �+rfY1f cb
Address d
r< City Fd rr- s 4 r4 4 lP.
" Registration No.
Operator's ignature
ease print tirmly BOARD OF HEALTH COPY 25M•10.115-8 07 1 0l
SOIL LOG
= NO. 1 O NO. 2
S I T E PLANIi sn
- 2 s4.53
- TOP OF FOUNDATION EL • - = '
8Y-
„` L 5 _
Do' IN El. ELJ6 4 ",. 10 i
r., s . •f, rE i
1 . Qrs IN.EL. IN.EL. 4 11
- -- - r -----� �o 2 COVER 1/8 3/8 WASHED STONE ,. r . 4 �.
IN.EI. a IN.EL. y - -- ° o ° ° ry `- 12
IN. El. �� G oo Boa ° ne y F"cD:
D/B W/ 6�� SUMP a • ° ° -�- --- 3/4 1 1/2 WASHED STONE -- 13
• 4- LIQUID LEVEL - • ° ° _._____ 14 `
a ° 0 °
C • b d � a o p
�• boo ° .` 6"EFF. DEPTH 15
-_i • °.• 6 e•-,� •• • . ° 0.3 � • b PERC TEST RESULTS
boo Off ' I cbp a
j PRECAST SEPTIC TANK WITH �o°°o o� ° o D ° PRECAST LEACHING PITS PERC RATE :
CAST IN PLACE INLET AND El. 4 ° 6 ° NO.: _Z_ SIZE : WHITNESSED BY :
OUTLET T "S PER TITLE .��/ 2 Y`: . . . _ Wit_ - -
. - t I - � DIA . \ -- BOARD OF HEALTH
SIZE . /� o� 6ALL0/V-S i` f _
No 0 rL WA-1 ov�vz LtE ,�e-1 ,&.fc„ DATE.
J s,c,C3, A 0"
PROFILE OF PROPOSED SEWAGE SYSTEM
��SYSTEM DESIGNED BY T�if TOWN OF — REGULATIONS AND
STATE TITLE Y FOR ,41JIBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4"= 1 ' 0
1111 N . B . 5�;� j
E
1 . All PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE 1
.� � a5 f
of �' � L j ( f '3'II F. 5 1 d C/ i EvJ/ A e)L ESL, e
2 All PIPES SHALL BE SLOPED 1/4 PER FOOT EXCEPT FOR � E aQ
t .� . . GifC c A LT C k_ Floes
I THE FIRST 2 FEET OUT OF THE D / B WHICH SHALL BE LEVEL so' 4C. �� f i A�'� "'�� ��'�'t �)
3 . DESIGN FLOW BEDROOMS AT 110 GALDAY PER BR. - GAL/DAY 7Av�
SEPTIC TANK SIZE X = GAL.
USE _,_ __moo GAL. W/ GARBAGE DISPOSAL
LEACHING 2 -
CH NG SYSTEM: USE
EFFECTIVE AREA . SIDE _ x:� �; t - %i� > \ 1 , �
,;p
z , 1
BOTTOM is - . ,� ; - �L �
TOTAL FLOW k � = io�g r�� z } 61 h _
TOTAL RE ' �; i. % = -
� oe ► ; /
D FLOW X
Q W/ GARBAGE DISPOSAL
T
RESERVE FLOW 8 G A L/DAY
REFERENCE PLANS :
3 Jrj,_ J t
APPROVED BY : I
r' � l.. �.n Tod nF' CZ EL �,4.99
— • -- — _ /� / 'ti� (� a4► S,► . C0Q-V6A, OF Lcs(a8 1
BOARD OF HEALTH
DATE :
PROPERTY OWNER SITE AND SEWAGE PLAN
FOR :
BEDROOM SINGLE FAMILY DWELLING
AF "L `A,UmT Jh DAL V t1E WN1F L tiJ , ! ;
LOT :
L) tri!s ! 8 � ;' ,,► 1D r3,f,- , �. ; F ;, e) ' ; DATE `zEv a- s-BL I
�`, J kI:t_ 1 r.. __FS�►Z Y1 AtJ iI
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