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HomeMy WebLinkAbout0171 GREAT HILL DRIVE - Health a� ].7 1. Great Hill Drive Marstons Mills A= 174— 022 s ,I �9 I'; r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Great Hill Drive lugProperty Address David C. Rooney Owner Owner's Name ryI/ I information is required for every West-�amstable VV'nnU� V�S (6S MA 02668 November 30,2010 - page. Cityrrown 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, ( Cod Iuse only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Environmental my Company Name 43 Triangle Circle Company Address Sandwich MA 02563 Cityrrown State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority November 30, 2010 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. U �. I t5ins-OWS rdle 5 Official Inspection Form:Subsurface Sever a Dis System•Page 1 0 17 9 YS 8 <I Commonwealth of'iWassachusetts Tithe 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not'for Voluntary Assessments 171 .Great`Hill Drive Property"Address: David C. Roon'ey Owner ;Owner's Name information is required West Barnstable MA 0266'8 .Rovember-30, 2010 for every - page. Gityrrown 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: have not found any information which indicatesthat any of the failure criteria described in 3.10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> Aseptic system is.deemed to pass this Real Estate Transfer Inspection if it does not trigger any of'the failure criteria listed below. The-septic system has been evaluated according to the conditions observed o,n the day it was inspected.No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of garbage grinder is.recommended. 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.oId*orthe-septic tank (whether metal or,not) is-structurally unsound, exhibits substantial infltrationorexfltration 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: 0 Y n N ❑ NO (Explain below): 15ins�09108 Title.S OfGgal,lnspedion Form:Subsurface Sewage Disposal System•Page2•of 17 Commonwealth-of"Massachusetts _ 'itle 5 Official Inspection F�o6rm Subsurface Sewage Disposal System Form -Not for'Voluntary Assessments 171 Great Hill Drive Property Address David C. Rooney Owner Owner's Name information is required for every West-Barnstable MA 02668: November 3Q, 2010 page. Cityrrown -State- Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (coat:):_ ❑ Observation of sewage backup or breakout or high static water leveiin the distribution box due to broken or obstructed pipe(s)or due to a broken settled or uneven distribution box..Systern 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 yeardue 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 bythe 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. 1.5.303(1)(0)that the system is not tfunetioning 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 i5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page3=o}fT SC;omYn_onwea'Ith'of:Massachusetts --VM TSitle 5: Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 111 Great Hill Drive Property Address David C. Rooney, Owner Owner's Name information.is required for every West Barnstable MA 02658 November 30 2010 - pager CityTrown 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 thesystenis functioning in a manner that protects the public health, safety and environment: ❑ The'system has.a septic;tank and-soil eibsorption.system (SAS)and the SAS is within 100'feet of a,surface water supply,or tributary to a surface water supply.. E' The system has.aseptic tank and SAS and the SAS is within a Zone 1 of a.public water supply. El The.system has aseptic;tank and,"SAS and the SAS is<within 50 feet of a private water Supply well, ❑' The system,has a septictank`and SAS and the SAS is less than 10O feet but50 feet.or more from a private watersupply-well**; Method Used to determine distance: **Th'is system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen.and nitrate nitrogen is equal to or less than 5'ppm,.provided;that ho.other failure criteria are triggered..A copy of the analysis must be attached to thisform 3. Other: D) System Failure.Criteria,Applicable to All Systems YOU must indicate"Yes" or"Nv"to each of thie fo lowing for all inspections: Yes No F-I © Backup of;sewage into facility or system component due:to overloaded or clogged SAS orcesspool- Discharge or, ponding of effluentto the-surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El R Stabogged SAS level i cesspool box above outlefinvert due to an overloaded or El Q Liquitl depth in cesspool is'less than 6" below;invert or available volume'is less than '/z day flow` t5ins•09/00- Title,5!QTtciaLlnspection;Form:Subsurface Sewage Disposal System-Page 4'o(t7 I Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Great Hill Drive Property Address David C. Rooney Owner Owner's Name information is required for every West Barnstable MA 02668 November 30, 2010 page, Cityfrown 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 11 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. t5irfs•09= rdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 or 17 Commonwealth of l assachusetts -4 - Titte 5 Offifc' al 1'nspection Form = S:ubsucface Sewage Disposal System Form :Not for Voluntary Assessments 171 Great Hill,Drive Prope4.Address David C. Rooney Owner OwneesName information is West Barnstable MA 026:68 November 30, 20,10' required for-every page.. Cttylrown State Zip Code Date of Inspection C. Checklist Check if the following have..been done.-You.roust indicate"yes`' or"no",as to each of the following: Yes No 0 ❑ Pumping,information was provided by the owner, occupant, or Board of Health ❑ 0 Were.any of the system.components pumped.out in-the previous two weeks? EI 0 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.'inspectioO Were as Wit plans.of.'the system obtained and examined? (I#they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up?' 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were.all.system components, excluding the SAS, located on site? ❑' Were:;the Septic tank inan.holeS OncoVered,,Opened,,and the interior of the tank inspected for the..Condition'of,the bafflesi.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 Ellinformation 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: 0 ❑ Existing information. For example, a plan at the Board of Wealth. 0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance.is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design):` 3 Number of bedrooms (actual): 2-3 DESIGN flow based'on 310 MR 15.203 (for example: 110;gpd x#of bedrooms): 330 gpd t5ins-:09/08 Tide 5`Offiaal,lnspeclion""Form:Subsurface.Sewage.Disposal System•Page 6 of 17 Commonwealth6,Massach' setts _ Title 5 Official Inspec tion form Subsurface Sewage disposal System Form-Not for Voluntary Assessmdrits _- 171 Great Hill Drive Property Address David.C. Rooney Owner Owner's Name information is required for every West Barnstable MA 02668 N6vernber`'30,2010 page. citylrown Stafe Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? Yes ❑ No Is laundry on a,separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes Z No Water meter readings, if available (last 2 years usage (gpd)): 226 gpd Detail: 2008, 2009, first half 2010 Sump,pump? ❑ Yes No 6 months ago .Last date of occupancy: Date Commercialllndustdal 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? [I Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins 0,9108" T Ne'S Official Inspection Form:Subsurface Sewage Disposal system,Page of 17 C-0,erh inrealth,ofryMassac etts hlus _ Tithe 5 Offical Inspection Form `Subsurface;Sewage Disposal System Form -Not.for'Voluntary Assessments 171 Great Hill Drive Property Address David C. Rooney Owner Owner's Name information is required for every West Barnstable MA 02668 November 30 2010 page. cityrrown State Zip Code. Date of Inspection A System, Informatiow(pont.) Lasttdate of occupa ipyluse Date Other(describe.below);` Genera H nformation Pumping Records Source of inforrtnation. Was system pumped as part of jhe inspection? ❑ Yes No If Yes, volume pumped_: gallons: How was quantity pumped determined?' Reason"for pumping:: Type of'Systern: z; 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) Ir novafive/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•09/W Title S official Inspection;Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 171 Great Hill Drive Property Address David C. Rooney Owner Owner's Name information is West Barnstaple MA 0266.8 November 3.0, required for every 2010 page. cityrrown State Zip code Date-of,lnspection D. System Information (cont.) Approximate age`of all components,date.installed (if known) and Source of'inforrnation: Age 20+ gears. Certificate of Compliance issued 12/20/1989 (Board of Health files) 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 ❑X 40'PVC other(:explain): Distance from private water supply well orsuction line: feet Comments (on condition of joints, venting, evidence of leakage; etc.): Sewer lire appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): 1 Depth bElow.grade: feet Material of Construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other,(explain) If tank is metal, list age: years Is age confirmed by a Certificate Of Compliance? (attach.a copy of Certificate)' ❑ Yes ❑ No Dimensions: 8:5 ft.x 6 ft..x,5 ft(1000 gal) Sludge depth: 6 in t5ins 091,08 Tdte;5.Offiaal Inspection Form:Subsudace Sewage Disposal System•.Pege.9 o1 17 Commonwealth-of Massachusetts Tithe 5 Off c a Inspection Form Subsurface,Sewage Disposal System'Form-Not for Voluntary Assessments w.� 171 Great Hill Drive Property Address David C. Rooney Owner 'Owner's Name information is requiredlo'r every West Barnstable MA; O2668 November 30, 2010. page. CityTrown State Zip,Code. Rate of Inspection D. System Information (:cent:.) Septic Tank (cent:) Distance,from top of sludge to bottom,of outlet tee otbaffle 28 In Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 0 in Distance.from.bottom of scum to bottom of outlet tee.or baffle 13 in How were dimensions determined? Design plan Comments_(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels:as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this;time but maintenance pumping is recommended withih and every two years. Tank appears-strueturally'-sound and functioning as intended. No evidence of leakage in or out Was observed Grease Trap (locate on site plan), Depth below grade: feet Material of construction: 0 concrete E metal El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 'Scum thickness Distance from to 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 15ins+09/08' Tille,5,Ofricial ImPectien Form:Subsurface Sewage Disposal system-.Page 10 of 17 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments 171 Great Hill Drive Property Address David C. Rooney Owner Owner's;Name information is West Barnstable MA 02668 November;30, 2010 required for every _ page. Cityrrown state Zip Code Date of Inspection D. System Information (cost.) 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. ler,'el: Alarm in working order: El 'Yes ❑ No Date of last pumping:' bate Comments (condition of alarm and floatswitches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Titles officiat Inspection form;Subsurface Sewago'Disposal System Page:1.1 of 17 Commonwealth of Massachuse,fts —� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti 171 Great Hiii Drive Property Address David'C,. Rooney, Owner Owne(s'Narne information is required forever' West Barnstable MA 02668 November 30, 2010 page; Ofty/Town State:_ Zip Gode Date of Inspection D. System 1 nformation (coat:) Distrr`bution Box(if present must-,be opened 11):(locate on,site plan): Depth of liquid level above'ouflef invert at outlet invert. Comrents.(note ifbox is levOland'distribution to,outlets equal, any evidence of solids carryover, any evidence;of leakage.into or out'of box, etc.): Pump Chamber'(locate on site_plan)` Pumps in,working:order: 0 Yes ❑ No Alarms in working order: Q Yes El No Comments(note condition of pump chamber, condition of pumps:and appurtenances,,etc.):. Soil Absorption System (SAS)'(locate;on site plan, excavation not required): If SAS not located., explain why: 15ins[•09108 Title 5.;Official Inspedion'Form:Subsuffaca Sewage Disposal System-Page12 of 17 Commonwealth of Massachusetts _ Title 5 Official inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Great Hill Drive Property Address David C. Rooney Owner Owners Name information is West Barnstable MA 02668 November 30 2010 required for every , page. City/Town State Zip Code bate of Inspection D. System Information (cont.) Type: leaching pits number: 1 ❑ leaching chambers number: leaching:gaileries number: ❑ Teaching 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.); Soils above leaching pit appear unsaturated. No evidence of'surface ponding, breakout; lush Vegetation, or other evidence of hydraulic failure was observed. An:observation hole was dug into leaching.pit stone and no standing effluent or effluent contact.staining_was observed in the top 1 foot of stone.or overlying soils. Cesspools(cesspool must be pumped as part:of inspection) (locate'on-'site plan): Num,ber and configuration Depth—tope 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•09108 Title 5 Official Inspection Form:-Subsurface Sewage Disposal System-.Page 13 of 17 Commonwealth of Massachusetts: _ Title 5 Offic:ial Inspection F-b"rm a Subsurface Sewage Disposal System Form.=Not for Voluntary Assessments 171 .Great-H ll Drive Property Address David C. Rooney Owner Owner's Name iequite►lon.e West,Barnstable MA, 02668 November,30,.201'0 required for.every ,.- page. Gttylrown, State; Zlp:Code We of Inspection D:.System Information (cont), Comments(;note,condition of soil`,=signs`of hydratalicibilure; level of ponding, condition of vegetation;. ete): Privy(locate on_aite plan);, Materials of'`construction Dimensions Depth of solids Comments.(note condition.of-soil, signs of f ydraulic:failure, level of pond ing,.condition of vegetation, etc:): t5ins•69108 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 14 of 17 - - - Commonwealth of Massachusetts. Tfti : 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 171 Great Hill Drive Property Address David C. Rooney Owner Owner's Name information is required for every West Barnstable MA 02668 November 30, 2Q10 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 1 GO feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately p i i ISin5d1)%08 Ti1i6,6 Official Impeclion Foim:.subsurface Sowage Disposal sysmm r Page 15 cf 17 �Commq`nweatth of'Massachuset#s it'l:e 5 `Officinal Inspection Form Subsurface Sewage Disposal System Form :Not for Voluntary Assessments 1`71 Great Hill Drive Property.Address David°C'. Rooney owner Owner's°Name information is bl t t Ba rnstable MA 02668 November 30, required for every 2010 page. Cityrrown State. Zip Code Date of Inspection D. System Information (cont.) Site Exam; M Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high`ground water' 20+ftfeet Please indicate all methods usedto deterrhine=the'high ground water elevation: Obtained from system design plans on record It checked, date of design n Ian reviewed: 1.0/16/84 P Date Z Observed'site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with.] - I;Board of Health -explain; 0 Checked VI!ith.local excavators, installers-(attach documentation), 0 Accessed US,GS.database. -explain;. You must describe how you'established the high ground water elevation: Approved-design plan on itie-with Board of Health shows bottom of soil absorption system to be 4+ feet:above the groundwater.table. System is 20 ft above street level. -Before-filing this,Inspection Report;please see Report Completeness Checklist on next page; 15ins•:09108 Title 5,Qfricialinspection Form:Subsurface Sewage Disposal Syslem.Page 16`,of 17 Commonwealth of-Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form<Not for`Voluntary Assessments 171 Great Hill Drive Property Address David C. Rooney Owner Owners Name information is West Barnstable MA 02668 November 30, required for every 2010 page. City/Town state Zip Code Date of Inspection E. Report Completeness Checklist ❑X 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 1.5 orattached in separate file t5ins:•09108 Title 5 Official Inspection Form:subsurface Sewage Disposal System Page 17 of t7 r 0 CATION SEWAGE PERMIT NO. VILLAGE I N S T L ER'S NAME i ADDRESS 8 U I L D E R OR OWNER Ce-�j4t---rLul' e- DATE PERMIT ISSUED /b1C� 3`/ DAT E COMPLIANCE ISSUED � � 2- r C s� No.._. _ �1 Fxs......... ............. .-- - s THE COMMONWEALTH OF MASSACHUSETTS A BOAR® OF HEALTH --...OF........................f34. --�"--�------ Appliration for Ilia uial 10ork.6 Cnnnitrnrtinn rrntit Application is hereby made for a Permit to Construct (,(/S or Repair ( ) an 'Individual 'ew Disposal System at: `1 _`` • ...�......_............................................. .............•-----•-....-• .. Location-Addr ss or No. , v r •- Address .... a ............................................. %�';t ------...--- � � .......................... Installer Address . U Type of Building Size Lot... feet Dwelling—No. of Bedrooms............._.__•--------------------Expansion Attic VV0 Garbage Grinder (�-�--- '� Other—Type of Building ............... No. of persons........_................... Showers — Cafeteria Ga Other fixtures --------------- ----------------•----- . W Design Flow.................�r................gallons per person per day. Total daily flow...........—�.J...0..................gallons. WSeptic Tank—Liquid c acityi,(QS�Zgallons 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. � f Test Pit No. 1... 5:...minutes per inch Depth of Test Pit.........}. Depth to ground water-----------lid Test Pit No. 2_Lilt lminutes per inch Depth-of Test Pit........ Depth to ground water........................ O .�... e 7 .. Description of Soil --------------------------------- V ------•-------•-2 7 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 iIT1Z 5 of the State Sanitary Code— The undersigned further agree not to place the system in operation until a Certificate of Compliance has been issued-lix the board o alth. Signed............... !... ............ .................... --7�2-7� Date Application Approved BY-----. __ ii -4---- --------------------•--------- ---•- =fly-.$ ...._.. Date Application Disapproved for the following reasons--------------------------------------------------------•-------••--------------------------•---------------... ..........................•---------•--••---•---•-•--------•-----------------------------------------•--------------------------•-•-----•-•-------•-••--•----•-•-•-•--•-----••--•-------------...._.._. Date PermitNo......................................................... Issued....................................................... Date No..... �...:.-•."�../ FEB.......... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c.t ,,,_ .............._.......---.........OF.........................1.T_A.=e-' ..........._-?....:_.. Appliration for Digpoli al Worka (fon,strnrtion fumit Application is hereby made for a Permit to Construct ( ``) or Repair ( ) an-Individual Sewag!rDisposal System at: _ . • ...........................................................................................-%.... ...---------......................-•--------------•--•-•----------....-----------................. J r5 Location Address / or Lot No. - ' . r L� /tlFrt a' �"ff}..-.... _................ .-•-^ ` ....................... ........ ......................... t Owner \ t Address! y . ...........................`_ ............. �... --..............................................._..... .__......................_.. Installer Address UType of Building _� Size Lot..`!F/..:1��>_. -----Sq. feet ,., Dwelling—No. of Bedrooms......:........ a_.___.....__....._...._..Expansion Attic 0-J Garbage Grinder (E }- `4 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 capacity!.Ql 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........I_F `T./4"K_.... as Test Pit No. 1..k-:F�tt S__.minutes per inch Depth of Test Pit. .....i..::.... Depth to ground water..._......."._.:-_ 44 Test Pit No. 2.. �? minutes per inch Depth of Test Pit....•.•..... .. Depth to ground water._..........tV.�`. - ' I !._......... �{ ..................................................:!:...___.:�...... __4„ .............:...__._.:_._..___.__.._________...__.___.....___..__._. O Description of Soil............................................. -------•----.�J .._ ................................' 'r{t: �-�. �-- . k r / '. 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 TITLE 5 of the State Sanitary Code— The undersigned further agree •not to place the system in operation until a Certificate of Compliance has been issued by the board ofthealth. <d Signed...............-=-r--f---.._ ....-:---- -------...-----•-------•--•-- ----. Date Application Approved By.................................`--------- =✓ Gf Date Application Disapproved for the following reasons---------------•-----...---------•-•-------------•--•---...----•----•-•----------•--•------•-••......-----•.--- ------------------------------•--...-----•-----•------.....-•---------------............------------------------.....------------------------•----------------------------------•---------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ 1 ! .... �'"� '......OF............ �. '' 't . .sE,; ':: ........................... Trrtifirtt#r of TontpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Dispos l/System constructed ( t)'or Repaired ( ) ,..t Installer �^ //•� at----•----•....••-••-••••-•------......•...............•••�•.-e ..... � �. l_.-"/''ye!�f� :~����� f A �aL_i.��/ t.e � A"1 has been installed in accordance with the provisions of TIT T j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No............."......�......_....._. d-ated_............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. -�._L d ® �' . Inspector---- h`' DATE........................•-----------................. ....__..._. !` �'_------------------------------------......................... " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF No.................�f/ FEE..... ............... Dispoul ork Permission,is hereby granted.................... J .o__#_ ..................__J_ _-------_-_ .................................. r to Construct (X or Repair ( ) an Individual Sewage Disposal System Y atNo.•-•••••-•--•---......---••••....................'-•......-••-...---j /l C`-r. . Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ---------------•--•-------....------......-----......_-•--•----.......•---- Board of Health DATE............................................................................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 1 SD i /wiz f' 7 r..: f� u KA w OF N \ ORSE - ~ i� �:• -=-._,.. . . � .\ � " .) r:���}d�! !I,• � It 1"� � � �, �''b , `O9�FcissE`�`�♦�``� l /. / r' F t> SSlONA1 E LEGEND �. . . LA/ \go z.s' Do ,� - z . { YEX STING ` SPOT ELEVATION OAO G = i CERTIFIED PLOT PLAN ,,fX:O$TINO CONTOUR --- 0 --—— ,�N Of'�q';,,� lNIS.H£D SPOT ELEVATION ROBERT G ` FIN SHED. CONTOUR 0 ©� BRUCE IN `AfPRQ:VEDl BOARD OF HEALTH 81A.9L9jbJ ASS* ELDREDG DATE AGENT No u �� SCALE` / — 40 DATE , 7>/_ 't GE EIVGINEERINIs CO. 0140 _ �071? , CLIENT._ i CERTIFY THAT THE PROPOSED g41STERE. REGISTERED JOR R®, �N-- BUILDING SHOWN ®N THIS PLAN CIVIL . LAND CONFORMS TO THE ZONING LAWS . Id0 NEER RY DR.BYt OF BARNSTAI�LE , MAS9, — 712. MAI N STREET' CH. By, �Q,, 3 �' r HYANNIS, MASS. SHEET OF DA E Eta. LAND SI�RVEYOR i n� N07"4ff /i-41/TNZ-q 7N&SFPT/G 7AoVik ®R C, 20 P7 /+s/N. LEACNiNG PJT ;4/�E.' IO pr.. /w/fit/ 1RA®JF� . C®�8r P SMAL L ®.F.,�.�eDtJi�-V 7' 7'® t".TA P W.64 IV ASK-- ,A J. Si'IaYC PJPZ GaNGR!'T'! i f/EAYy CA ST/M.ON CoVEJT Sh/AL.L_ BE USFT1? - ' W/M. P/TCN E�, 37 fl covER.S /J=//v o.RiVEyVAY 1 —Ilia OoE" Cov CO E/� CLEAN ,5i41V O &AC.+CF/L L L/1941/0 LEVI L _ 2 LAYER. 4- d CA AT/� /000 .► o o - ' t /69!/i/.P/TGN 7��sAL. ' r e ® . . . s • • •. • e. •,• WASH£-O 5mmc _ s BOX o ! o � e r • •• • .rr • 3/40 ' ::;,' • D • �.!.• �EPTJ•/ • • • • e � e 14/ASHEd> .S7`®��' t i ' f SSfX ?S 4-70 • • • 1 I • • • 4 s ! • `='•:i .7 ff r 7.� = �S s s' • o • e • • s 0.0 j,a r PRECAST.SE. 9GE` s .� • • • '• • si • • ® P/TOR N/V. t A/6r�RT �� 6/A�0�41/d p/T C�f T y ► , ® � L I b,s �®AMS /2`�;o FT 6 FT D�ANP• INLET .SiE/�"/tC T.�/1/K. / z6pFT /� FT. O/AJ - (SEE7 r INYZAT AT 0/✓I J®iv� OdITLET S&PT/C TANK 1 ZS.a PT. -.. lHzk-r OJSTi4/" ON ®OX /1 S.Z/�'j �'EC7-10AI OF Grp®uNC .I1G4TEI� Ts E - - 0tl7ZE7D/37RsBtPr'JOJv BOX-1/S:o FT .SEWAt 5AS ®/SPASA 4 aS9�.S7 W�'1 /NL6'7' LEACHING J�/T l 145 FT ?XW"TION DES/61v CRITERIA . /.a /. D/�*!�/vs/onI $ 6 FT. NdJ�l�ER D�BEO�OOM.S TOTAL EST/MEO /�'LC�/ 33 O C�4L./oAY. SO J L TEST / SOIL.7ZrST,0� SO/d. '7�E$T l �^�G EK �`-EL�Y, ,OA7 ®sue' S 1/3. /ti(UMBER � LEAC/d/p/G P/7r3 //�:S - - .S/OF LPACMJNG AER PIT RESIIL'TS 6V/7NESSFJ> jr a ®O TTOM L$y1 G/!/NG PER .n/T �$ /`T �;•' L o,4 /"I A-- Ae2 C C.i A IoN RATA#/ 4-1 M//b1/r cN AREA SP. 0/ Z 1�(� �. sv3 5 L !�/�C®J��/®M R.e9�'� 02 -7-P-A/V M/N- /NCN 7'OTAL LEACHIMCP F7. Z o f .Q'�3�RVE� ✓4�'/dJNcs,p1R�/� Z. L' 5Q. FT. _ 3 '`. L Y ?~ L a 7" /5� / ROBEHT C,y P��N DFM�SS4c fir/ TL= 2,� VIZ E t BRU E /~ �✓e c` ALB ELDRED - CQ, , F pe/ N6 10951 O 71,g /�fA1N '.9T.I flYA SUS �o� ��SSE ��� ® No ePTOUNP yY,�rZR JrJVCouNrEic.-o C�%Five%�E�ni�rz�c-2 ATE Zv�v^g' fsSl0NA%%-Ea [� G/CO llNl�. Yv6!7'FR AT A -v v z .IOB /bt0. g 3 Z y q JHB�T _Oir