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0207 CINDERELLA TERRACE - Health
( 207 Cinderella Terrace Marstons Mills P A = 047 109 _ r f CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 3/12/2007 Jason G.Brown Order No.: G0739703 207 Cinderella Terrace Marstons Mills, MA 02648 Laboratory ID#:1 0739703-01 Description: Water-Drinking Water Sample#: Sampling Location 207 Cinderella Terrace,Marstons Mills,MA Collected: 3n12007 Collected by: J.Brown v Received: 3n12007 Routine ITEM RESULT UNITS RL MCL Method# Tested Nitrate as Nitrogen 1.6 mg/L 0.10 10 EPA 300.0 3/7/2007 Copper 0.48 mg/L 0.10 1.3 SM 3111B 3/9/2007 Iron 0.14 mg/L 0.10 0.3 SM 3111B 3/9/2007 Sodium 15 mg/L 1.0 20 SM 3111B 3/9/2007 Total Coliform Absent P/A 0 0 SM9223 3/7/2007 Conductance 110 umohs/cm 2.0 EPA 120.1 3/7/2007 pH 6.0 pH-units 0 EPA 150.1 3/7/2007 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By- ab Director) 4 j V CT) Z S �1 U, r In S ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 207 Cinderella Terrace G� �y Marston Mills. MA 02648 00) Owner's Name: Ken Terkelsen Owner's Address: 319 Cairn Ridge 7 E. Falmouth, MA 02536 Date of Inspection: August 30, 2006 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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 perfonned,based on my r- 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- r . i 7_-) i ✓ Passes Or% _.,. Conditionally Passes ; Need Further Evaluation by the Local Approving Authority Fail tt� Inspector's Signature: Date: Aujzust 31 2006 The system inspector shall subrn a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 207 Cinderella Terrace Marston Mills. MA Owner: Ken Terkelsen Date of Inspection: August 30, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed. distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 207 Cinderella Terrace Marston Mills. MA Owner: Ken Terkelsen Date of Inspection: August 30, 2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to'a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 207 Cinderella Terrace Marstons Mills. MA Owner: Ken Terkelsen Date of Inspection: August 30, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool . ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gP d. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water,supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r t Page 5 of 11 ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 207 Cinderella Terrace Marston Mills, MA Owner: Ken Terkelsen Date of Inspection: August 30, 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 nonnal 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: 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)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 207 Cinde,-ella Terrace Marston Mills: MA Owner: Ken Terkelsen Date of Inspection: August 30, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2+ Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): n/a Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM !i ✓ 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed on 3116186-per as built card Were sewage odors detected when arriving at the site(yes or no): No I 6 • Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 207 Cinderella Terrace Marstons Mills. MA Owner: Ken Terkelsen Date of Inspection: August 30, 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 32" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 8" 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 detennined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present. The liquid level was even with the outlet invert. There did not appear to be any s_ igns of leakage. Recommend pumping tank. A niece of plywood was covering the hole. The owner agreed to install a new cement cover. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recomrendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 207 Cinderella Terrace Marston Mills. MA Owner: Ken Terkelsen Date of Inspection: Aujzust 30, 2006 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments note if box is level and distribution( .tribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Conunents(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 207 Cinderella Terrace Marstons Mills, MA Owner: Ken Terkelsen Date of Inspection: Aygust 30, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 ag l.)-per as built card 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.): One pit 01)was dry and clean. The scum line was 6"up from the bottom. The other vit 02)was located but not duP up There did not appear to be any signs of failure. CESSPOOLS: None (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 or no): Commments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 207 Cinderella Terrace Marston Mills, MA Owner: Ken Terkelsen Date of Inspection: August 30, 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. V (3 tiz 3 10 Page I of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 207 Cinderella Terrace Marstons Mills, MA Owner: Ken Terkelsen. Date of Inspection: August 30, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 50'+/-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properiy in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 I t COMMONWEALTH OF MASSACHUSETTS, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION \4 l . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 1 2, Property Address: 00 14, eiirx�a 0 Owner's Name:c9en 14 �" �l Owner's.Address: / p,Lc . tDo U00 Date of Inspection: Name of Inspector: (please print) -,!!( - B01406 Company Name Mailing Address: 0• AP41, 0 81� sQ (�Cp TAY- 0� fy Telephone Number: - PARCEL ' CERTIFICATION STATEMENT LOT I certify that I have personally inspected the sewage disposal system at this address and that the information repo ed . below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems..I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: __-'_/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _ Date: L 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. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title.5 Inspection Form 6/15/20.00 page 1 r r Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:,-,Jo 17 zl2ml-oh,Z ✓l�➢,r o J4 � r•. Owner: �, Date of Inspection: y.�,e,vt , /�C1)()0a Inspection Summary: Check A,B,C;D or E/ALWAYS cornplete.all of Section D A. S stem Passes:. I have not found an inf ormation tton which mdicates that any of the failure criteria describe_d in 310 CMR 15.303'or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated belovr. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon'completion of the replacement or repair; as approved by the Board of Health, AJ11 pass. 'A F .Answer yes,no or not determined-(Y;N;ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*'or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or.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. ND explain: Observation of sewage backup or break out or dish static water'level�an the distribution box due to'broken or obstructed pi.pe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): -broken pipe(s)are replaced obstruction is removed distribution box is.leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I ' Page 3.of 11 OFFICIAL INSPECTION FORM-- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �({>�� /7— Owner: ,�✓CC '.�GC` Date of Inspection: j G� 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 Ts failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that the system is not functioning in a manner which will protect public health,safety and the.environment: — Cesspool or privy is within 50 feet of a surface water. — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of.Health (and Public Water Supplier, if any)..determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the.SAS is within 160 feet of a. surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less-Ithan,5 ppm; provided that'.no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACIE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:(1_zW12j Date of Inspection: / Da D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N 1� Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pondirig 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 over]oaded 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 J 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 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 failure criteria exist as described in.340 CMR 15.303,therefore.the system fails.The system owner should contact the Board of Health to determine what will be necessary to correctthe failure. E.. Large Systems: To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 gpd• You must indicate either"yes" or"no"to each of the following:. (The following criteria apply to large systems in addition to the criteria above) yes, .no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is:located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any questibn in Section E the system is considered a significant threat, or answered "yes" in Section D above the Iarge 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. 4 Page 5 of 1.1 OFFICIAL. INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:,:;`0.-) iUA Owner. 52 Date of Inspection: 6U� 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 _i,1-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?. _V _ 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? i� Was the facility owner(and occupants if different from owner)provided,with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ 'Existing information. For example, a plan at the Board of Health. J _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CX4R 15.302(3)(b)] 5 . Page.6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: % lh Owner: Date of Inspection: wl^ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): Q DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): _ Number of current residents-��,C&//Ly1 Does residence have a garbage grinder(yes or no)z, . _ Is laundry on a separate sewage system es'or no if es se arat ii s eciion re uired x; 5 y (y ) L, Y P P q Laundry system inspecte . yes or notzb— Seasonal use: (yes or no) Water meter readings, if a ailable(last 2 years usage(gpd)): l� Sump pump(yes on Last date of occupancy. CO MMERCIAL/INDUSTRIAL—A - Type of establishment: Design flow(based on 310 CMR`15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER;(describe): GENERAL INFORMATION Pumping Records Source of.information: Was system pumped as part of the inspecti (yes or no)• dr- If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM _AZSeptic Tank,-distribution box, soil'absorption system _Single cesspool Overflow cesspool _Privy _Shared system (yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attacli a copyof the DEP approval i Other(describe): -- - pproximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no) 6. IPage 7 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1�30 Owner: aaa Date of Inspection:i BUILDING SEWER(locate on site plan) - Depth below.grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance-from private water supply well or suction line: Comments(on condition of joints, venting;evidence of leakage,etc.): , SEPTIC TANK: (locate on site plan) Depth below grade:L— Material of construction: cvEoncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �•$ ')((o .k ` Sludge depth: 0,5'' Distance from top of sludge to bottom of outlet tee.or baffle: , 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: Comments(on pumping recommendations;inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) i� V GREASE TRA (locate on site plan) i Depth below grade:_ Material of construction:_concrete__metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUIRSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 1 _ n/M'4 IA Owner Date of Inspection: U� TIGHT or HOLDING TANK✓1 (tank must be pumped at time of inspection)(]ocate on site.plan) Depth below.grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions:'_ Capacity: gallons Design Flow:._ gallons/day Alarm present(yes or no): Alarm level:_ Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: V (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert. Comments(note if box is leve' and distribution to outlets equal, any evidence of solids carryover, any evidence of eakage into or out of box, etc.): 717 PUMP CHAMBER:/(locate on site plan) Pumps in working order(yes or no): Alarms in working order.(y_es or,no):_ Comments(note condition of pump chamber.,condition of pumps and appurtenances, etc.): 8 i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: G 3xe or-�Gl.� Date of Inspection SOIL ABSORPTION SYSTEM (SAS):—I,.- (locate on site plan, excavation not required) If SAS not located explain why: /leachin Type g Pits,number: _....._... leaching chambers,number: leaching galleries,number: leaching trenches;number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, ,_etc): 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 or no): 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ow Owner Date of Inspection: �pUa 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. �. --� o �1 Cho I 10 Page l 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75VAO-c _ MA Owner: �" _ a,� Date of Inspection: SITE EXAM Slope Surface water Check.cellar Shallow-wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 D.eC,T.,ic U-Mber: Couple: .. by:.- . C.OMPUT A T lON Site Location: 2—e7 OW—net;. �e e_ iWAdd.ress_ Contractor: ©�/,V// ` Address: votes:. Mec^SU•re deo? h 0-W2ter tcbl.e :o near e:it. Date 2 ' � _ rno�tfiicaY/year I _ Using.Wa e Le:vel.R-ange Z'one and I l&,',.x 'hieil.>tA:z.p:loca- Sit an.d:aetem ne: O ,;ppro.pria.e.indexwet!_........._. i ..o U eve! �._nc —one; cr ........................ _.__.._._.. :. EP;;:3:: Usine nolttnfy.repar..- "Curl=n•t Wetef f""sOU�C2s:COndlt!OnS determine CUrrenL-d_p-.th.Lo . Water revel 70r•lndcx vvel'I 1. J X.>=P• Usinc.Tz;�'ie.a;•�Nate�-l.ev?I =;C)uS�mentS t' ,I =or in well ES.TcP 2. ),;cdcrtint death to water ;or.i•nde?<well {'STEEP 3), and.\uaCer-lwjei zone (STEP-<B) i 43' oererm!na w a •atzr eve, G1.LS lE tt ..............._._ � —ca- _ =s:!ma'<e iept .o water by subt;:actipe; :=.Water--• level @djus m=_nt-(CSTcP ^—,-) ;01-1 rnez<�.red.d=pt1 to.water level ac sc:.e.lSTt '1)' ....... a ..................................... c_ , C35y�� .........v......�_,..v�...c..'^Tm.re..�..w.�._-3...-w.....,.._...... _._ ._.e......�..�+c-+^`..^'^^ �...,,w�.,..,—�iA�.®.,,..,.e..-m..e,.,,,..,�,..,a,..�..�..��le-%,,�c..•���,�Jj L� ...�..w...e.„� L66 Tli; V _/000 ! Mr � �l s ll� TOWN OF BARNSTABLE d CI� per LI T SEWAGE # LOCATION t7�0� l VU,Lp�GE /h• M 1 l s ASSESSOR'S MAP & LOT '1T f 09 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) P. S (size) NO.OF BEDROOMS II BUILDER OR OWNER PERMITDATE: 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 l on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by or c. _C C4 oC1 L^ s � t� Lz-r -p 7 _ o y LOCATION SEWAGE PERMIT NO. VILLAGE L°T '-7 C.j � t INSTALLER'S NAME A ADDRESS � UZ673 B U I L D E R OR 40WN Elf DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �� t Ni :9Z o�q by rr1 � o ti 21 m.. a A f No.....F.6_1.7 Fxs.....?!s................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....:77V; n. o F n s ��,-.................................................. Allp iratiun for Uiipnsal lVarkii Tontitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal System at: J4 .................................................................................................. ocation-Address or Lot No. ........£fi r . , 1�, -----------------------------------------Owner ? �11 11i 35 . Address �/n �. ............ Installer Address Type of Building Size Lot----------------------------Sq. feet _ U Dwelling—No. of Bedrooms............7...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures ............................... .. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........-••••-•---••--•-•--------•-------------••......--•--••-•••----•-- Date...................................... Test Pit No. 1...........:....minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R ODescription of Soil........................................................................................................................................................................ U ---------------- -------••-•----------------------------------------------------------••-----------------•---•---------------•----•--•-----------------------•----•----•-----•------------ W __ U l�ture of Repairs or Alter�tions— nswer when applicable_1-rJ ---___•..h-�u��'e�-�:�in�••�•.-�o��j�- ...................................................................................................................................... am__hoctse_ o.�e�a�Fi,r. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with the provisions of TI'i LZ 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. Si ned--- -•--- . ---- ..............•--•---. 3'/0' � Date Application Approved B3�`"�`------------••-•-• .--...b 3 ^ -g ,. ............•------ .� .' Date Application Disapproved for the f ollowi reasons:................................................................................................................ -•........................•--•-•-•---•--...--•-------•-••-•••----------•-•••-•-----•-•-•-•...._...........................•••-----•------•---•---•--••---•.............................................. Date PermitNo......................................................... Issued....................................................... Date r No......................... FEE.... ...._".......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF.....f`.r,rns...f.h.........-----•--- Appliration for Disposal Works Tonstrnrtiun JIrrmit Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal System at: ..... G �, ►r� E4_....l. rrc!e , tij r �. '.!��S ............................................•--------------•------•----------.._....------....---- n 33 Location Address - or t o. •�-- .......................�n �i....Cr;�,n (�I rt c�S21?I0 ... �7- Frg?��rrz tF ra _... ...R.,I15____ nn c! (� If Owner r} Address ! W AI R_ �g/1C� . 15 �lt?�� ll�rr_r�n��ra�h__ _______ ............• n....------•----•••....._...---•..........................••.... ....................................................._.. Installer Address 1 Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures .........................-----•--••-----------------------------------•----------------•--------------------------------------__.------............. W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity_____._.....gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ �-7 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------•-------------------•------------------........-----....-----------•--••--......---••--•..................................... ----.----- 0 Description of Soil...................................................................................................................................................................... U ---•-----------•-----------••--------------•----••--•------------•-----------...-•------------•---•---....----------•---•-••---------•-----------•-----------------------........_.......--•-•--------- W ---•-----•---•--------------••••------------------...•--•---•••--•---------------------•--------•--------•---------•- ..........................y...............................................-- . ------- U tnrrr_ Repairs or Alterations GYAnswer when applicable--l.rr zr --T. c.e�--lt�r..-............;/ -- .-- lrrrc'.. i � II Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 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 theboard/of health. Si ned.. �kpf,. irtcckL.. __ P__ j�a.... - ,p n Date Application Approved By....................... ------------••-- ......... ._J_ --` Date Application Disapproved for the f ollowi reasons:--•---•-------•••---------------•---------•------••------------•-------------•-----------------------.....-•-- .....................•--------------------•-------•-•-------.......-------•------•----••--...-----...................----•---------------------------------------------_..•-------•-------•---......----- Date PermitNo......................................................... Issued_....................................................... Date f THE COMMONWEALTH OF MASSACHUSETTS - �U�l BOARD OF HEALTH ....!� (vcwvt 0F. t^r11 LI(n— ...................................................................... (9rdifiratr of Tontpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� ) by---------------------------------•-.A....6..-•----.... -•----••-----------••--•--------------•--......---------•--.......---...............---......---•-•-•-----•--------- f Installer at------------•-----------------•------..0..........------- f . ....... .i'_)(-y.6. ----------------.............................................. has been installed in accordance with the provisions of TITLr, 5 of The State Sanitary Code as escribed in the application for Disposal Works Construction Permit No----- .............. dated....... _ _JD. _�-6._..._._........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA AN EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ PATE.................... l).�1/je&............................... Inspector.................AA �f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No........................ FEE...!...:.. .......... Disposal Vorks %I-Paanstrudilan rrntit Permission is hereby granted........... _4.._C..........-- -A-.1'1 C�-O••----•---------------•--- -----------••............................•---......--. to Construct ( ) or Repair K ) an Individual Sewage Disposal System atNo. e--------•-------------------------_----------- .. --....... Street as shown on the application for Disposal Works Construction Permit N6r?.6:.- Dated.......... -:: •- y - `lB�ar aI[7 1? --- ------ ...._... DATE.............. -r Q- -q 6 l ----•-...--- J FORM 1255 A. M. SULKIN, INC., BOSTON 1 {F N / THE COMMONWEALTH OF MASSACHUSETTS �- BOARD pOF HEALTH /.'-i�-------------OF........�J./� �tf�P /'Y 1 ' Appliration for Disposal Works Ton.strnrtinn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ZV ...................... ..C......... .,.e.....'. .....I..a..1. a ' ------------•--- ...................................... Location-Address or Lot No. .................. G,�. ��vs�r --boa..... .v.F..�lobs --•--•. -_..... Owner Address W Installer Address PQ UType of Building Size Lot..._._ _6.✓-_`�..Sq. feet I—I Dwelling—No. of Bedrooms__ ........................ pansio tic rbage Grinder -Other—TYPe of Building ------------------------•-- No. of a sons..........- •-------------- Showers Cafeteria Otherfixtures --------------------• ......•-•-•--•............ ••--•--•-•-•-••••-.•-•-•----•---......•-••-••••-- ( ) -(----)--....................................... W Design Flow...........................................g 11ons r per on p r day. Tot aily flow.............. ............................gallons. WSeptic Tank—Liquid capacity��... lions L t .............. Width_.....___.__.. Diamete ................ Depth........_..:__.. W Disposal Trench—No. ............... ... W'Ith................... of Length.................. Total lea ing area....................sq. ft. Seepage Pit No_______ _________ Dieter.. ..x> ... Dep h b low inlet............. .... Total Ching area..................sq. ft. Z Other Distribution box (jC) Dosing tank ( ) aPercolation Test Results �C`rformcby -----------------•-- --•• Date Test Pit No. I................ inutes p inch Depth of est Pit................... e h to ground water---_------------------- Test est Pit No. 2................ inutes pe inch Depth of T st Pit................... D th to ground water........................ P4 ' --•••-•..............................................................................•-• •.. ......................................................... ODescrip 'on of Soil.................. .............................................. .................-----•------....... ................................ ................= - U ---------•-•--•••••• ...----••••----•-•••--••------•-•-••-•••..........•�......•-=_•:...-- W ; r U Nature of epairs or Altera ions—Ans er when applica le..... ....................................................................................... ----------------- --••-•••••.. ........................................................ ............................. Agreement: The unde igned agre s to install th aforedescrib d Individual Sewage Disposal System in accordance with the provisions o.T I':I.E of the State Sa itary Code The undersigned further agrees not to place the system in operation until a' ertifica.te of Compliance ha been iss ed by the bo rd f ealth. d ------ Application Approve By.. -= ....... -- ........ .................... `s/T Date Application Disapprov d f o the following reasons----------------•--------------------------------------•-------•------------------------••---•--.�...•...--._ ......................................... --•••--•--•-•••---•---•••-•----••--•••-•-._.......-•-•••...•-'-•-••••••._.......••••----•••••-•••-•••••-••••-••••--------•-•-•--------......-•-••••.......... Date PermitNo....................................................... Issued....................................................... Date ..................... .............•............... ...•...••••.••..••••...••....•••..••..•.•••..••.••.••••.•.•••••...•.•......•...•..•.••.•. r THE COMMONWEALTH OF MASSACHUSETTS ~-- ' BOARD OF HEALTH . .........................................OF.. o® dw wrtifirFa#r of Tom liFanrr THIS IS TO CERTIFY; That the Indivj'dual Sew e Disposal System constructed ( ) or Repaired ( ) e by-- -•-- -•-------.---•-------•--•----------•I................... ,A !v ------...........................--••-------•-•----------•----•--•.._....---- -•-...._. at...... 24----•` ---- C J---/....----- Ins l y r } ' l G7L ._.�1 1 1 ...... has-been installed in accordance with the provisions of TI T LB�.j Of Theme State Sanitary Co d scr' ed in the application for Disposal Works Construction Permit No._' ..... `+� 7 dated--------- .? .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE, SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... ....................................................................•..................................`.................. THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH ( 35 0 7 ...........................................OF...................................................................................... p = —. Disposal Works Tonstrnduan rumit Permission is hereby granted............................ ....G:� ..� .......... ... .•°" to Construct ) or Repair ) an I ,ivi D'soosa ual Sem ge l System Street as shown on the application for Disposal Works Construction Permit N Date . • . ........................... _G� . DATE Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON - C F� ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6: ..............OF.-.-...�. jo-l-V �. f�,c3GG Appliratiuia for Uisvo,seal Works Tonstrurfiun ramit Application is hereby made for a Permit to Construct ( ) or-Repair ( ) an Individual Sewage Disposal System at: ..... ... -'----...-- .................... Location-Address or Lot No W Owner Address ----------------------------•------•-•----......_._._..._..._...........-••-••--••-....----- .................................................................................................. Installer Address Type of Building Size Lot_�KZ_ •�_:' 2._Sq. feet �-, Dwelling—No. of Bedrooms.............._Z.........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons......=................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------•----•--------------------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacit}V�1._!Q�gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area--------------_-----sq. ft. Seepage Pit No......Z----------- Diameter_ X -:_- Depth below inlet____________________ Total leaching area----..............sq. ft. z Other Distribution box 0[) Dosing tank ( ) Percolation Test Results Performed by---••-•-------•--•-•• = Date a ; Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------------------------------------------- •------•-•-•-------------------------••-------••••-•---------------••-------..................... 0 Description of Soil....................................................................------------------------------------ = x U •-•••-••••-•••••••••.....•••----••--••...-•••--••-•••••••-••-_...-••-••-••-•-••-•-••••-•-•----•---•--••-•••-•••••••--•---•-••••--•-•----•-••--=-•-••••-••-•---•••••-•••-•-•-•--••---...•----•----•••••- W 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 T ITLE 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 bo rd ealth. Application Approved By..----'- `'� `z _�,.�C: � " an4 •-•-•-•-- • .............. ...........................••-•- Date Application Disapproved for the following reasons:................................................................................................................ ....................................................... ••----•-•-••--•••-••-•-••--.._..--•••••-...-••-•-••••••-•_.-.••----------•---------------------------------------------------------------------- Date PermitNo...................................-..................... Issued_...................................................... Daft THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF......-......:......................_......._._......._............................. (5rdifirtttr of (tumplinurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( ) by--------•••----•--•••-._..._...-•--••-••--••-••••---•--•--------•••••--•...... ...::...••••• •---•---...-------•-•.......•------•--•------•...................----.._....... ---•-. .. L,4 Inst dl at------1�. , ...... D-I.......... has been installed in accordance with the provisions of TITLE ofe��tate Sanitary Code de-as-described in the application for Disposal Works Construction Permit No._.__. :____________________________ dated__ .-_____- e a��_ ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. = ........... Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r OF .... ......... Disposal Works 0-Funo#ri ion "rani# Permissionis hereby granted--------------------•.---------------------•----•••--••-••••••-•••••••••-••••••••••........................................................ to Construct (>9 or.Repair ( ) an Individ al Sew ge Di osal System x - Street as shown on the application for Disposal Works Construction Permit Date - �..yt a Board of Health -. DATE........-....................................................................... FORM 1255, A. M. SULKIN, INC., BOSTON ,I /o.o fppoo - 17 g e A � � SL4�ep 0 \ , l- /z 5 D G�➢L SF�JTic TAN.L� - • "�3' y t�.s+cyncl rS I. � 1 5 i 1 C -� L O Cs9 7�1a S1L3S IA �-- 6 9 � _ (._,A !- may— Ao O� Sll L. E- `r Oro f ,EXi s 7ic�G J,f P p S� Tic _ -r314 _ _ ® C -� � o C,g Tea ti ✓� tv oq p �� C7 ,• - \ On si s� -No...J.q.4.._-•--.. Fsa.............................. THE COMMONWEALTH OF MASSACHUSETTS �a ROAD® OF HEALTH �UOAJ. ........... OF............. .�4C.SL �.�. ....... Appliration -for Uii wig l Works ( ouBtrurtion Vrruift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal P-,,,System at ................. cation- dd ess or Lot 'o. ......__... - ------------•--------------- -•------ ---------------------- �Owne Address ' Installer Address Type of Building -3 Size Lot............................Sq. feet Dwelling—No. of Bte- ©oms Expansion Attic. ( ) Garbage Grinder ( ) per-, Other'—Type of 13, :inf e— Now+ of persons ..____.__ --_________.__ Showers ( ) — Cafeteria ( ) Other W ds per pe son pDesign Flow-------------- er day. Total daily flow------------------------------- g allons. P41 Septic Tank—Liquid caplcttvl gall Length---------------- Width.----_. . .--- Diameter..... ... _..... Depth... -. Disposal TrenchLength .. �� t —No `� Wt�t11z``________________ Total Length_ ---__---._______-- Total leaching area.-_-.-..---. __---sq. ft. / J O Seepage PitNo.._____ k t. Diameter _ ..80._.._ Depth below inlet____________________ Total leaching area...----_.._.-___sci. ft. Z y g tank O n PercolattionrrTest Results Performed by t -`. '_______________ Date /f .: k a ........... Date------------------------------------ Test Pit No. 1----------------minutes per inch .Depth of Test Pit.................... Depth to ground water.._---:.---.-.--_..__. LT, Test Pit No. 2................minutes per inch,,,O,'epth of.Test Pit-------------------- Depth.to ground water-------------_,--__-__._ o =4 j,,/ / ------ Description of Soil '"�"�'+ti1 ` T lJ E. fi - - -- ------------------------------ W, SCh.0 �1 ,l ....... ........(...-.............---------------------------- x ----------------------- -------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- V 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 Article XI 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-------1- -GG,...k-to, /J- J� Date Application Approved By---- Date Application Disapproved for the following reasons:........................................-----------------_-----------••-----•-•----------------------------- .............•------•--•------------•--------•---•----------•------.....------.......----•----------•--.---------••----..----------- .......................---------- ... = ... ------ Date 74/ Permit No. 1 r�-------------== Issued-------------------- -------f........... ............. Date ThA,/1 THE COMMONWEALTH OF MASSACHUSETTS JP/ft ffd A BOARD OF HEALTH �fTslG.la/................OF.......� �E.. .ST.�4L -..........................-::.........- °1 Trrtifira$r of Tompliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by.........,p[ ---------�y GGec„5 T.................. l' ------------------------------------------------------------------------------------------ LUT 7 I.... r haass been installed in accordance with the provisions of Article XI of The State S nitary. Code�as described in the application for Dis o s, .-Works Construction Permit No.--_L-7-. . THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ��=Z - 11- --7- - ............................... Inspector------ ,.:. ------•--•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................Apt........OF..--...-14h-1-lT-.- �� '... ......... ,;No.------�� • -------- FEE........................ �t����M� �trk� �>a�t�trllr�ti�8t rruttf Permission is hereby granted----------- ...... - ............................................. to Construct O or Repair ( ) an Individual Sewage Disposal System at No... U - 7- ��1 ��Gh.--------;L�l.. -- - • r /GGj - - - ''I Street as shown on the application for Dispos l Works Construction Permit No...�W--------- Dated ----------- ------------- -----------•---•----------=-----------------........................................... DATE............... .11 1 Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS l .......... FEs............................... THE COMMONWEALTH OF'MASSACHUSETTS BOARD OF HEALTH uGuJjl...... .......OF.............. ASrlf A.I..< Apphration -for Di!ipwial Works Tatuitrurtion Prrutit Applic'atim--is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: A 4)7- ele ir ts ................... ;............................................. ....................... ......................................................................................... jR#j kation-kd e Lot 0. sA/,I-r 6, r...... ......................................................................................... . ..... it.........U7. .......... .,..o n Adduss/ ............T tit W ........... ... ......... .. ........... % A($ .......... ..................................... ier-----I- ---------- ---------*---------- - -----------Installer Address U Type of Building Size Lot----------------------------Sq. feet 3 Dwelling—No. of Bedrooms- --------------------Expansion Attic Garbage Grinder PL, Other—Type of Building ---- No. of persons----------2------------------ Showers Cafeteria ..................... Otherfi_�ctures ......... ------------------------------------------------------------------------------------------------------------ Design Flow............................................gallons per person per day. Total daily flow------- --------------------------------------gallons. C4 -septic T'Luk:Liquid capacity 0—gallonsLength________________ Width..._..._.._.... Diameter___._......._.._ Depth.___--_-.--... x Disposal Trench— o- -------------------- Wid 11---- ------- Total Length._..._.__...____._.. Total leaching area--------__--- -----sq. ft. Seepage Pit Diameter__.9)(F-- Depth below inlet____________________ Total leaching area------------------sq. f t. Other Distribution box Dosing tank Percolation Test Results Performed'by-------------------------------------------------------------------------- Date-------------- ------------ ----------- Test Pit No. 1_--------------minutes per inch Depth of Test Pit_._________________- Depth to ground water------------------------- (14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ J if................... - --------- 0 -----d-------------------------- ' , ra�- � ......X"�_r------------------------ Description of Soil...... ...... . ............. , j �4 P------- .... .... ......-- ----------- - ---------------------------------------- ----------------------- -------------------- ----------------- .....�.& * U ....... ---------------------------------------------------- -------------------------------------- --------------------------------------------------I---------------------------------------------------------------------------------------------------------------------------------------- ------------- 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 Article XI of the State Sanitary Code—The uridersigned ftmtljeragrees-net•to,place the system in operation until a Certificate of,_QqvppIiance has been,issued by the oard'6f fi6alth,.,- "' < Sign( ... ................... %4................ Date ApplicationApproved BY--- --- --------------------------------------------------------------------------------- ---------------------------------------- Date Application Disapproved for the following reasons:...................... ............. I....................................................................... ........................................................................................................................................................................................................ J_'/? Date Issued._..._._.. ....e....f..................... Permit No.....Z?.V------------------------------------------ Date THE COMMONWEALTH OF MASSACHUSETTS vv Irr-- BOARD OF HEALTH 0"/r ....... ...................0 F.........4A.A.A..T .............. .................. Tprfifirate of TIMplialtre THI,aS IS TO CERTIFY That the Individugj Sewage Disposal System constructed or Repaired b ................y........ ...... .................................................................................................. Installer to ...........................................................11_0(f.11&--------- ........................................................................... ................. s been a` '�imled in accordance with the prbvisions of Article XI of The State Sanitary Code as described in the application for 3....7.6/ Disposal s..Construction Permit ---_--------------- -dated------------/ .. ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....1--X!JI!..241---------------------- ... ----------- Inspector................. ......................14....................................... THE COMMONWEALTH OF MASSA'CHUSETTS BOARD bk ,AEALTH- No....... ........ .................. FEE........................ Permission is hereby granted------------ .............d ........ ............................................ to Construct (� ) or Repair an Individual Sewa e Disposal System at No_4pn........../_?........ ............ 1W. A-11L-.4 5 Street as shown on the a for Disposal Works Consi�b-cti.oti-"Pefttiit . .--No ?.'"t .......... Dated___----- pplication fo ............ ..................................................................................................... Board of Health DATE.......................................................... ............. FORM 1255 HOBBS & WARREN,._INC.. PUBLISHERS ii, "V, 'g