Loading...
HomeMy WebLinkAbout0128 HIGHPOINT ROAD - Health 128- High;point`Road :Marstons,Mills P -_ (A27,'032 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 r 11-6-14 I s or'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. t5ins-3/13 ,. Title 5 i i I I s ection Form:S� rfa� a lis osa System P 9 P I y Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15'.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 IL c Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 99 P ❑ ® 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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- 1 0,000g pd. ❑ ® 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 El ❑ 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �7M 128 Hi9 P h oint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd z#of bedrooms): 220 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �qM 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well 9 ( y 9 (gP ))= Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11-2014 Date Commercial/Industrial Flow Conditions: Type of Establishment: -Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap.present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 - _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--within last 2yrs Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach-a copy of the DEP approval. ❑ Other(describe): t5ins•3/13- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1977 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. i Septic Tank(locate on site plan): Depth below grade: 12"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: 1000 gal Sludge depth: 12" t5ins-3113 j Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts = W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is r required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1,y 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts = W Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 128 Highpoint Rd Property Address Anthony Spaguolo , Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers r r number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and holding water at 40" below inlet invert. Stain line at 36" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is Marstons Mills MA 02648 11-6-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts = w Title 5 Official Inspection Form �s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 128 Highpoint Rd i.. Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a D i i .. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts m W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 128 Highpoint Rd Property Address Anthony Spaguolo Owner Owner's Name information is required for every Marstons Mills MA 02648 11-6-14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 2 u3 A -\ COMMONWEALTH OF MASSACHUSETTS EXUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �® Pi,;art !O _ _„_ .. ��P 0 7 2004. LOT TOVVI�Of- BARNSTABLE• TITLE 5 HEALTH DEPT. . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: o ' R t30 M$ owner's Name: S�eve Qanf Owner's Address: 2 oo"n i ars164s ,M,1/s.MA oa6 9 Date of Inspection: Name of Inspector:(plegse print Jhc w/1 Company Name: S.M. F.+ ee- r ses Mailing Address: cZ w Q� T 1-hikie Nuiiiber:;.St)'Fi-q9S-0905 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am'a DEP approved systeuf iuspector pursuant to Section15.340 of Title 5(310 CMR 15.000). The-system: . ✓ asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: dZ� 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,o00 V'Ll yr 9feater,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 Comment 5a i L ln e i n leAGI► :f' s a 36 "" !mil . , ****This report only describes conditions at the time of inspection and under the Conditions of use at that time.This inspection does out address how the system will perform in the future under the same or different conditions of use. T41.S T»e_ov` n ti r.'_ 4/iShMl1 r— s Page 2 of I i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION(continued) Property Address: 6 dd�1q -9A'7Q' ' Owner: Date of Inspection: -0 inspectien Summary:"C'neck A;B,C,D or E i ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicates that any of the failure criteria described iit 310 CNIR 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 enfiltration 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. N"D 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 Hoard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled orreplaced 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 f ND explain: ti Page 3 of l l OFFICIAL'INSPECT ON FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION(continued) Property Address: Q Y t{i 44 Da rh f - ,444r's+Lc , �2:Lls Owner: Date of inspection: 8- 1,0 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 CINIR 15.303(l)(b)that the system is not fur..:.ioniag in a manor 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 i.• 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 l 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 fCa 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: Page 4 of 11 OFFICIAL INSPECTIN FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:A' . CERTIFICATION(cotitinued) Property Address: Or 4 Owner: Date of inspection: D. System Failure Criteria applicable to an systems: You must indicate`fires'or"no"to each of the following for all inspections: Yes Ng/ /Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge orponding of effluent to the surface of the ground or surface waters due.to an overloaded or /clogged SAS or cesspool V 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 1/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped _ �I///Any pomon of the SAS,cesspool or privy is below high ground water elevation. (/ Any portion of cesspool or privy is within I00 feet of a surface water supply or tributary to a surface /water supply. ✓./Any portion of a cesspool or privy is within a Zone I 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 indiesies that the well is free from pollution from that facHiiy"d the presence of ammonia ,iReogea 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.1 )(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 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 _ r 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 courtact the appropriate regional office of the Department. Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEVvAGE DISPOSAL SYSTEM INSPECTION FORM,' PART,B CHECKLIST• Property Address: 07 R Owner: Date of Inspection: $ 1 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes N ✓o _ Pumping information was provided by the owner,occupant,or Board of Health / ✓ Were any of the system components pumped out in the previous two weeks'? Has the system received normal flows in the previous two week period Have large volumes of water been introduced to the system recently or as part of this inspection? LI/ Were as built plans of the system obtained and examined?of they were not available note as lei/A) V/_ 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 th/e 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: Ye. no Existing information.For example,a plan at the Board of Health. — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTPON FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION Property address: 1o?khl.!�4 DaM f 6/ Owner: Date of Inspection: '(9 FLOW CONDITIONS RESIDENTL4,L Number of bedrooms(design): a- Number of bedrooms(actual):_� , DESIGN flow based on 3I0 CUR 15.203(for example: 1110 gpd x#of bedroucus): eZaU Number of current residents: 1 Does residence have a garbage grinder(yes or no):AO Is laundry on a separate sewage system'yes or no):_p[if yes separate inspection required] Laundry system inspected(yes or no): o Seasonal use:(yes or no): o A Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): #0 Last date of occupancy: $�2! COMMERCLUJINDUSTRIAL Type of establishment Design flow(based on 310 CMR 15.203): epd 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 occupancyluse: OTHER(describe): - GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part ofthe inspection(yes or no}:_ If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPR OF SYSTEM Septic tank, 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 c:upy of the DEP approval _.Other(describe): Approximate age of all components,date installed(if known)and source of information: L 577 Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of I I OFFICIAL INSPECIVON FORM—NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION(continued) Property Address: $ !. f Owner: Date of Inspection: fr-a r-ay BUILDING SEWER(locate on site plan) e, Dcpth below grade: $,"" , , } Materials of construction: -9/cast iron T40 PVC—other(explain): aid PUG Distance from private water supply well ur ruction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade:_ / Material of construction:_tCconcrete metal fiberglass_-polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /000 64/, Sludge depth: Distance from top of s udge to bottom of outlet tee or baffle: cK$ Scum thickness: _ si Distance from top of scum to top of outlet tee or baffle.- Distance from bottom of scum to bottom ofpputlet tee or baffle: /(o r� How were dimensions determined:_ A e Tc.4/ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade.i Material of construction:_concz+ete 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): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• t.. Rd i s Owner: Date of Inspection: 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(explam): Dimensions: Capacity: gallons Design Flow: ¢allonsfday Alarm present(yes or no): Alamo level: Alarm in working order(yes or no).— Date of last pumping- Comments(condition of alarm and float switches,etc.): DISTREBUTION BOX: (if present must be opened)(iocate on site plan) ' Depth of liquid level above outlet invert ' Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes orno): ` Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): • i , Page 9 of I 1 OFFICIAL INSPECTfON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C SYSTEM INFORMATION(continued) Property Address: �.2 r&g A p T,,J A/ Afars A"s At.?I s Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type/ V leaching pits,number. _leaching chambers,number. _teaching 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.): %1 qO-adl eay, .Ti DYE CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—tap of liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool- Materials of construction: Indication ofgroundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of pon&g,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,): Page 10 of 1 i OFFICIAL INSPECTthN FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /off f )�ifZjQaAf Rd' a 7 Owner: Date of inspection: 'V ?1-Ot/ 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. D D A ac B la-4-9- 8 c- 35' A-a-ly'y�� r o a A-L 77' LE- S1,16" Ito w pa.-�.f'4a r_. f Page 11 of 11 OFFICIAL INSPECTON FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE.DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: laQJk or t IW4'5 6. s Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4/4'�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 �Qbserved 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 USES database-explain: You must descn a how you es lishe the high ground water elevation: 5 GS 4 n v a a cF /- I II ..�v SuP�gce $It 6�.eticl, .,t pry ► s 4r Be�� Title 5 inspection Form 61,512000 11 c 6 37' r r �f S , No.-Qiaw---AP Fee-------- BOARD OF HEALTH TOWN OF BARNSTABLE Applitat ion Ar Vell Congtructioll Permit Application is hereby made for permit to,C nstruct Alter or Repair an individual Well at: L—oca—tion'-- Address Assessors Map and Parcel wner Address Installer Driller Address Type of Building Dwelling Other - Type of Building No. of —-------- rr Type of Well--4W—&— Capacity------------ Purpose of Well--- Agreement: The undersigned agrees to install the aforidescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signt! date Application Approved By . .......... - date Application Disapproved for the following reasons: —--------- date Permit No. Issued date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate (of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed Altered or Repaired Ge--< I Iler at /j Coe ---—-------------—------------ ------ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated----------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------- Inspector v, L No.-- Fee------- ------ '' BOARD OF HEALTH ' TOWN OF BARNSTABLE t Application for Well Con0ructionpermit � Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair Vran individual Well at: / Location'-- Address Assessors Map and Parcel Owner Address nr ,taller — Driller lJ Address Type of Building Dwelling ----------------------------- Other - Type of Building---______—_____________ No. of Persons----------------------------------- Type of Well �/l �l /—,_——_ Capacity--------- --—---- -—— ~, Purpose of Well---- Ir. - t Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signe �--_ -------------- date Application Approved By -- --=----— --------- date Application Disapproved for the following reasons:----------- --- —— —-- ---—---— date Permit No. - -- Issued----- -- - ----- -- ----- date r BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (!�'� by----- � -- - ------------------ ----- Ingaller at -------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. --------``=---Dated------ ------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------- - —-- Inspector-- - -= ---------------- —--——--- BOARD OF HEALTH TOWN OF BARNSTABLE Well Congtruct ion Aertnit No. -6��;- -�G 3 Fee- - --- � Permission is hereby granted-��--��,^-�/�'l/ A_ lz to Construct ( ), Alter ( ), or Repair ( an ��idual Wellat:No. — - %F -��-.•: .• l�S �`-------- - -- ---------------------------- (/ r _ Street as shown on the application for a Well Construction Permit No. Lated Board of Health DATE TOWN OF BAMSTABLE ,OCA� 'It]N. ��, SiaV1 PAGE VILLA��Ia Mars� /�l ,r ASSFSSOWS MAP 3't D48T j,. EWS NAM EA PHONE NO. ACI et NO OFB61DR0.0NdS a PixFMT➢A. .''. C�s1�Y� Yt�TdCE`T�P+?�'f"' Soprarae►o�t�b5taan�c:Bc�tv�eera t110 MAximuml�cl}ustrtl�tautadw�a�et'@'abletotlact3cttrorn:�i�et�i:hingl��tr�ility :�.. '��'r�'` laalVOW Leachttag Aci#aty �S�a�y cii�i�s cxls9 �c r38 aci g�t�,ac WOW �o0 fect F.cti: y�WetSant9c1d.Leaalll�i�ys�cit¢y(1E uny wetlndti exist c r riitt�ui�00 fret at: s �upS�'ucils 1 ���✓ C © w ell ti L&CATION SEWAGE PERMIT NO. I-D 3 -i VILLAGE'dzy y� INSTA LLE' 'S * NAME & ADDRESS . C® FPeled gj,1_ooL B U I'L D_E II OR OWN ER DATE PERMIT ISSUED 3 , 77 DATE COMPLIANCE ISSUED -�G � 7-7 ' ti,� // W! Y, r �r� ��. �� �„ ' THE COMMONWEALTH OF MASSACH SETS BOARD OF HEALTH owA/ .. ..._.....__....OF....�3A .►�ST�..l.3LC.._..:...+.................................. .�lipIiratinn -fur Uiiipaoal Works Tnnitrnrtinn Urrntit Application is hereby made for a Permit to Construct (✓ ) or ,Repair ( ) an Individual Sewage Disposal System at: A ,�J ............... 1� 11JG STa�/t......b-ST,4TE S �° � ���� ly�6k�inl r ?1�......-••-•-------. Location-rti�gdss or Lotowlo �6 . �_-t_. a�ie-}Y� �"�lC: �-�T/�EEN_%yA2�c� ....--...t.:� �R�SNFicL� 11RSS.............•--• •.re Address I Installer Address dType of BuildinV g Size Lot-46,.-Q_40-Q---------Sq. feet U Dwelling o. of Bedrooms..------- 7...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures --.----_--_--- -------------- W Design Flow--------- s d......................gallons r person per day. Total daily flow-_______3!20......._................gallons. WSeptic Tank—Liquid capacity/44d_---gallons Length---------------- Width_-------------. Diameter---------------- Depth.._.-_-----.---- x Disposal Trench—No-____________________ Width.................... Total Length--_-___-i-__..___--- Total leaching area....................sq. ft. Seepage Pit No..______�_________/Diameter___-_o....... Depth below inlet.?... ....... Total leacllittg area. _.._..-.sq. ft. APP z Other Distribution box (X) DosiV tank ( ) _ '-' Percolation Test Results Performed b lC . C7. C. L� Date./._ i..�L__�f7� O135 Test-Pit No. 1................minutes per inch Depth of Test Pit..._.. . Depth to ground water_. a!�L.-_.--_..l (s, Test Pit No. 2....z--------minutes per inch Depth of Test Pit____________________ Depth to ground water-_.-.- ._-- 5. ••-••-•------•------------------•••---------------•---•••••••...............---•--•---••......••----......................... .......-- O Description of Soil---- DB.-e7 - i�i d�,E'oWN S 13So%L_._` I `78.0--- -_ D. O r'_'--•.-_ x --------------------------------` h-----••----------- ._ .. � ............ ..s v� U - O� RODERT ��r .•. x ------------- ---------- ------ ---------------------- D----- �47 ----ENd-v__uwtMeEb- --------------------------- �--------- a:-------- -- w V Nature of Repairs or Alterations—Answer when applicable._.............................................................. -----McGLONE---- -------------------------------------- .. (7 A ------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in �n�ce the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place operation until a Certificate of Compliance has b by the board of health. a Signed __... .e....�--..------•- ------. --`;.................. ...... 1--' Date Application Approved By------------------------------------------------------- ••----•••....... ........ ---------------------- --•----- ate Application Disapproved for the following r asons: '^.. _ . ....... / Date 77 AC Permit No........�0----..............................v— + Issued-----......^ ---I----- Date No. ..................... ....._-•••••... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I . ''a OF. `'ti t ... . E" tit.................................................... Appliration lor.43wp teal Works Tomitrnrtiun Prrmit Application is hereby made for a Permit to Construct (+°) or Repair ( } an Individual Sewage Disposal System at: f �. Location-Add X . --�,- ss ° or Lot No _ r2L .. '��_... `4 €a;e cssy r1 L=.... "-- f. ! d t e�e�tD r �; U l t7: A� �_±c � 14AI 5-5 . caner Address Installer Address Type of Buildings Size Lot 0.QP.Q-____-____Sq. feet Dwelling • No. of Bedrooms----------_______________________________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________ 't ....................gallons. Septic Tank—Liquid capacity ' ____gallons Length---------------- Width------ Diameter-----.---------- Depth.._--_-___--_-. xDisposal Trench—No_ ____________________ Width.................... Total Length------------------.. Total leaching area...__-____-___-_-_-_sq. ft. Seepage Pit No----- Diameter_ __^:_Q_..____ Depth below inlet__"'C'_______ Total leaching area-°�W---_____sq. ft. Z Other Distribution box (✓ ) Dosing, tank '-' Percolation Test Results Performed by._ o ._... _.......n.____ Date./............................ . ,al Qua Test'Pit No. 1................minutes per inch Depth of "Pest Pit.__._ ___._ Depth to ground water.lkt!(. f= Test Pit No. 2....e_-------minutes per inch Depth of Test Pit_____ ____________ Depth to ground water------------------------ ----- O Description of Soil �f_iQ� � 70, ''' �P ------ --------------- -------- x rSrt�` nl O`' y^� c� = J �i W °1 rr /' ' � }``1L ftfatAr R ------------------- ------------------- '-� x ... ...GGOR1----------�`- .. V Nature of Repairs or Alterations—Answer when applicable._._.________________________________________________ _ ............ --------------------------------------------------'------•------------------------•----------•-••----•-•••-•••-- .... R -------------o Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systerc with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to p stem in operation until a Certificate of Compliance has been is y the b and of health. _..-. Signed-- ��a-- � -------•----------------- �{,-•..--.r Date ApplicationApproved BY F ----------------------------------- ------------------------ ---------------------------------------- Date Application Disapproved for the following reasons:----- -- - -- ---- ..............t--------------•------- - ---- ------- �t-•••-- � -- ate PermitNo..........t J� -------------=••-•.................. Issued.------ --------------------------................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q _ _ l�I........................oF... '�t . f?1 ..�"�..... L— .__T._R_ ffl firatr of 101umPlianrie THIS IS 0 `ERTIFY, �hayf'� ndividual Sewage Disposal System constructed (�) or Repaired ( ) by-- ---------------------------------------------•----••-•--•-------------- A Installer.............../ ---------- at...................` -�...................tX `F�1E1CG�_�7�[91��------j9��?"I�s ---------------------------------------------------------------------------------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descr,bed in the application for Disposal Works Construction Permit No------ J- __________________________ dated..-____::�_____--'_--_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM Vt/ LL FUNCTION SATISFACTORY. DATE---- -•`•-=•Ap------ -----------•-•-•••---•---••--•-•-•---- Inspector----------�C-------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /r? �a ........................O F...,�'�.(i !`� `�?d No......................... FEE........................ Vn% l grk ` nrtilattrrmit � � -Permission is hereby granted--- ------------ ------ -- ----- - �--- --------------......................................-.............................. to Construct (I� or Repair ( ) ndividual Sewage Disposal System h _.__.__. ______________________________________________________________________ street j t as shown on the application for Disposal Works Construction Per o.__. _ _:_.__ ated__________________________________________ --••--_---- -- -- ----- --- ----- - _•__ DATE...... - :77� - 77.-...------- •-------- ••-••---••••-•••----•-•- Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i A;(v A=5 AL-do e(ti e"is Z.OGE A. No. 971 - ,` v. > \ '•ti�ti- v 1 -+�. --v `..:E 1,_� •:.4' �,..,v \� vi.`- �. \�� Gx!liJj it 'Gr l..t. t ,r' MA J4 N IF w 0 0 l Ll) lilt'••• ' � �: 71SEI2 Ur OP-APP NcN 2x�rg, I(Di'A.G tI- ;Ir j To � ExiST'�, Zx3 g, CA T° '`•� �eLt/i,P1 W/eX, G,�N;!L.aV�t2 ..` � b. o p r � �G _!� I<Pal' i 1 ( F12L1t'!INGr oor.+O, Ft 7..l..a,1,L'! s IVII �. - r 1 a r t 'ti 1 ^ it t r rr i' FAGE Gt=' �t- f,-r" I! 1 :tl '���{ it _ -- F LV9 2 0, �UT��v,�r -VA g, /1 WALL-) � 2 i N10 i (2)2x8 � s otJ;?c elNg± i��uv� iFs t - — - - — — - -L----- -- — i i �.— —L� r _- — — - _ Z O PT!alJj 4x�PiTd FD57 ON ! + ! �±ET, �'R 6 N ` ' T>J ii lYv�GiJea ACbOV,t �. ,. �� tip; TO !F=£N E4, FLo/12 GMiD�i?ANC !r' ��\4 i ! I—!— i `Its ! Ii, f *�yt� i e' �• .. ; ., ` 1F T' - 1 't 5 ' +#.. !'t ! XtS;_& �3�2xog rsrllE►. 4 ' ! _---=_ _ ___ 'L = —=- --__- =--�!t II.._ r I ~``t ._MIN._ X �8._r�GGE !r✓ —rl---- — —. — —{.....1-�C• i—_L._ .:, •� -- --------�. .:± t e x4 t(2)2x35 c..�'�,-',' b .-SYlas ,.'aw:,.:� t'tS,•§6`��.,W 1.'1., .s,. M+ 3 .... 'N. C ZT tJ2 ; O )`lX8 tztNa0�'��J Ph} tYcoTiDA c F k rkN7iI:N V�2 ! \ At7A.N ENT,'1'f ht0.g. � Zx.i.o.s�..lfo.0, � i � 4 \ �1 \� It. � ��F i L�tiU � Stt7i✓•i�'(i: �' � .... t 1 � \U ILLIN GiGA. ! c / X HIND ,�(u v� b "� I 1 _ � �2 c>`t ; Ito"o G• @ �or���r. I; I bo_.�.T�p To,�x .t?�to5,E ?/. 1 51�+PsoN Gp�Niu�r OlAil-ca-4,V,A+�G•AGr-' -' = N. M oil �oNa"NvEi I i inn o,G. ETA r6tE frD• i ( ! W� F3F � BtG..Feo I �:: 1 I I —.. — — . �.. —. \ I '/ ` Foo I i'f'fP• j j 11 p i I • 1`a\NX �� °V R' ..'tea i�'1� 's,� Y -'' vS �. \��`'\'t vv,�';�° •`. 9±`Qu ExtSTibr L,�N'f tL 6V IQ jc l5T r! �YGAMitJG �GoVrI ----R— �'�t- 0�, �± O N EN FouNDaT?ON FX 11T' NOUN D,a-no*" I�t30v 2 60 r 1 r�11 t jd I/[1+a (y'—l+a 17iL A � p-�� � 1 � 1 - r I \R► t 3yZ, ✓�=31� rr I+1 311 'L Sr_ �,o �3�z'' 1! - !o��✓tu V. !,F. (Ex/s7's) fl Lo C Its vi J I n t It /� + 3 y O ' �''4 op ° Z I 5-10" 2 ., .p• '} �-7 0 � �..� _..� -;_._; - ' �-• -'— —-— ✓ r: ..:, J.t, n. —_.i.__._;e•r>. ,a ,::`d: is .?✓r r �✓tr� - - -— ,a.� :n Y , I i M IQ HALL `� 2 __. GkAN�E AQov ew,� ry I �� --• _ _ a N ... _ _.. ' it i `I `\ .Kr<., ,2d;.._"i:r.;'•,'. :";:�"...'#r.Ear :.�.�_ 1 q 1 •r , ,1 1 ' - I i f ,z I . Vr 3-II -vo • Jr t V 1 r. . ---- ° i i +. _. . H. �-[e`i2' I �' I ! VP 1 -)T 6.N. ; lip j D5k• 3On I a't Fz — T i I I� F r' — �• :15• �or:.r+� j l y' 1 iZEF• 7 .. � �J � I w i I.�. t �O ` r, I © V a- 13/ S y y_9 'I- .. /i All 11,4 Nth! .r�t.�17 zja_G" I `moo NEjc1• r 1 A-Ar 3,f"X SZ�" Ica --- fNSU JxL k _ _ \,mot I 3,/sy i , 3� rl ,` , 11 / J / ,• _ ft 1 to !/- I �- �� •� 2-u�/� ' 3lZ !i -� la /w 3'�' � z � I � to n 1 f l Ul ` �. j II tc1.: VL �. N t qo O 1 1 s I I ! I ({ } a v Y 3/yX?l`gRLVL{i�<.�S�Z ABOVE 9 r Z � g^ � • _ ���IPENt/•16t WSIt�G'rL6 PI.f�TC. I I . ' I r i I 1 i i � .�', a ..:,r.::. f;::�.:. „u'1... -y ,.f'. :lX ! .;:f: '•,1..✓ ,[-y. .,�. _— _. _ —_ ---_---- — �, wsT,R.'.. .av —�1 I � — � ' 1 . 1. ..I ri� i' r• , 1 17 , i ,. „` "1 71 ty , l-Id��t 2-t1 3/y".j I I _ I I I Z 1 /n i ..�e a �p .3fZ �. i I i I ' i } } j i 1 j ` 1 I 4 rl J1—4✓+�t�7 I Z — �2 I M - 3 { � LL { I I I — I . j I - " h � �OPSN TO �p ; i t 1 i i 1 I A,N Ht*t 30 z 22' ++� _a> ._—— — tJil.FIN• RAG 1J � � `.. , n INSy41. AacESsDR. � � � i ZQ i t V t4 P-I N I E,P ;Or , I� I I I I I I I ( 1 i it i I } � I t f I j i ( j i ! I ! ' f j I ! III � i I I I � f l i i � ! t r l t 1' I • I � il , � � � � ; , ; I , '; ,; , ; , , �: � I ; ; � i ; ll , i � l ► ! , , II, � _1_�_ l i1 �� _ !111 ; , ii ; � �-� ' I � , _I_� _li -1, �► �.- __ : ,� ;� 'i-- 1 li T� I "T 1 la leAFi 5 G/G o.G, I;� I to I II I ---_ _ I.......... I. I Zx 8 C/2."o.G• Ba-lN sIv es oa 1 r 0 s6 i- F5. PAP r/E To ALIC,N w/ s/sir-) I up F7r, 2,6 k✓/ --'� 1 To Nac 1 x r 4vzj�- i I (2)Zx s ti/ K S/h/ps-oN L u S Z4, fix, ),4 T1�S, 4 0.� — I I� ADEr /+cN, I SrsrF,e Uw Ek.&C. s c.✓� _` I I 1 I : I r � I I � q � I r Z,S rn, 2xs G�6.Jarsl > 1 I I i H6AvF9 [i@LOW Top Tor PLATE • ev'r To ¢" HIarH To A"61 VJ FtZ' G 11 A GPNTINuE Tor ToP PLATE GDNT• ,44tOp 5. GJ�GD'N D f=1.00'k2....�M�A-M I r�.C�- P.�A� . _ � tP,A-��,�" y. h ,. MfzS, ANT?1o.NY..-�Pr46N o.L^o�. l � NI�iH.PtrINT. f�l?) G,, h1�i°UI"i .�"°f;dr o rocs, n Y T D C b € bR7 F ; 0 CT 0 E3Ice, Ns9 �d3�� y� EA ! m 7169 MA OF MPSgP HZ,5 @I LN to"p,o MI — ISPHAii..sl-}IN6�>'S pre 3olETHIN.tO jF �.- 30 clGd tNSUL• i1lN .3-o'QF..-IGEs �JP�T..E12 GlkiL`I.D.�i A,LI �1 � 4OF_E ES QY1s? F,r!1 I I?F, .R I 110N y} 3 ;12 P 17-6:H ON VO f2. - Poe SHE THING *� N&W r10o1-51 F-X, -_-- �SH8�71trNG. � �X^Qo✓G. r NEI O NEB JtJ x 105@ �'U C -r:•2 _�x(a_GL6e-n��_II�''o �N�T <I 0/01Od/124 OA6fi CONNto-,n 1,w J tl6hDER . 'i'iP Pt-h•t& L9 LOFT?,l•CBL, y r .4 ®_E.A) IN.ai__W�!L.� OPENING"tic i�r!? 85" `�iisT p� ..IZ I3 "FISIW6DL 1�` $' tVArM-MAa.416R• ON Wf"TS►z ►dA0-n 11 15 68}tsr+l._cE LT Q�ER iN FL .pl.r WEN i�5W-uoN .:.QA N LX,"A. 1D—`'iP. - 6EhR{N&-Wl4L': i Q t ['LrrJ b�}i r,a'FH ING QN _2X4.5?�d w,at.L: - — — -- — -- — — -- -- 00 -T•a-EX,2 Ft,SU6Fi. ; Q" t f.l.OoR.lOI4 Ib' f` rli —— Gnsibr,:r 1 r 51_NELa-F2�a .•�.ZxB-.. � _ T.c. tx. Det:PLAN ` , !!T_E 1QED GO►�i. _ 5O FF i V EsT 51ST&,M -0P aDDP TOE �x ✓ • PX tIS' �4 °° ALIGN LJ N6N J,ojhT,5jAPD NEW {� Y a � PI.NW S D ' u13FG. �1.UER � NNELED ; �. Ex Lx6E 136Ae2ING ,ALL Z b xf ' ',air ENI TO6ELi1:JL` ? � +� i Z � v INFILL G:a BAl.6 P o/2x69+iPv"®,G�� y flQ ��W r(,,rw p" y0P✓FG ENG 0S6: r-,-.x, six&-rl& �FlN,Ivltar I OL (Z) EX aB&AR+N&► LI Ex, a15ry Ib O,G• r �} ®,EX.tAFL•SUDEL. A • 'f.e• �o bAT10rJ 6'o",T J.Q1 .�-BEZw�EN- Ex_.�..2�8�s�l�"o,E - ;_• i _N GA TIL•EV6P 2-0"T® hA H Il W j F1►N'r K'-f9 r�6r .,INSuI . I �- O u1{ • B><, GONG. FOUNDp?IQNf FOo't � � S Lea IS ( a ►► (LED ARC. A. CIA No.9716 FA OUTH, R':3o rfG' 1 0•t7r3u. PL�hTi 'OF MP''�P Symbol Manufacturer Type# R.O.Width R.O.Height T.O.R.O. Wall type/Quantity off subfloor= Comments ! ' ( I = k fl' t.o.fin.floor u.n.o. A Therma-Tru 3'-0"x 6'-8" 3'-2 1/2" 6'-10 1/2" 6'-10 1/2" 2x4 stud wall/one li I Z Smooth Star S236 Hinged Inswing u Door ` ,r✓c a.) �,t_.F�.}IGh•�`j "1'2..�11,N.t21 b,t�._�_ 2 X 10_ I ._..-- .. � ; 'ii �,"t tt 4NGt-tG1 _13O'.Th-_P�12.Ct91�E_At�:4N.3V .X --.._ _.. I F !`,v 2x8's � tL O,G •_ 1 (=�•SL�FI.i C\: t^ -'- B Therma-Tru 2'-8"x 6'-8"S82 4'-1 1/2" 6'-10 1/2" 6'-10 1/2" 2x4 stud wall/one Smooth Star w/14" S92SL With cont.sill and —T a FeutjDA-n-j Z `� Hinged Inswing storm/screen door. $ 4 Nt FOWVP TION 0/(1) _5.6AP-. C'nof' ---- Ada w/exls?o,. a 2 r Door w/sidel't Ns; tl? Lk C Andersen Frenchwood 9'-3 3/4" 6'-11" 6'-11" 2x4 stud wall/one °x lo° cJ G, Gliding Door DAAS_�'..9.a7fO•t�. _._ _ ... __.. _.. i '0 2 �' 1 FWG 100611-4 ;I 3"M1u: DU5?GAPi t s . D Andersen Tilt Wash 2'-2 1/8" 3'-8 7/8" 6'-10 3/4" 2x4 stud wall/five s' �G hit PoJ(Double Hung Frame R.O.window cr PAcTSV oAvNE1D2 RL I o 0 TW2036 opening facing road , in Mudroom for °FO t2.. P EIiT�ON..�.. A=Ai 13-r'3 . Q Z potential future . 2'-8"x 6'-8"door, Z infill as needed. E Andersen Tilt Wash 4'-5 3/4" 4'-4 7/8" 6'-10 3/4" 2x4 stud wall/two Z Double Hung (2)TW2042 w/ n 2"support u mull l PP ¢x!2 RIDGE l2 .<t detail 9 — - r F Andersen Tilt Wash 2'-6 1/8" 4'-0 7/8" 6'-10 3/4"on 2x4 stud wall/six / O A u^1 Dist D E G Double Hung 1" floor .J ytMP N p12,��1r�'o,G�( rt V ,!vl6T5 TW24310 6'-8" t4 tom; 4 4 1 N t on 2nd floor _ —_ 2X$ .GEILLN� .lOi-5T5 @.l(m Oe.G•__. ,'`' -.. T.G• pg�,pt.A'r$ � G Andersen Tilt Wash 2'-6 1/8" 4'-8 7/8" 6'-10 3/4" 2x4 stud wall/three i Double Hung fed/IZ d �� L5 aAG► for►N t;��1aN r TW2446 �l II G�►+T.lN.U-4.-11.5_._i �ZxA_P LATE, �. .. � v H Andersen Tilt Wash 5'-1 3/4" 4'-8 7/8" 6'-10 3/4" 2x4 stud wall/one !I [41.4!s;NP hJAIs. NiN_,.t�:_i.31 ++ 3 Double Hung i MA INSUL, * VAP P_ 6AaJZ1SC '\N (2)TW2446 w/ ON V�tN?at2_WA�2ri c,tDz 2 Z 2"support mull detail I 2 _ ....._ J Andersen Awning 6-2 1/2" 2'-0 1/8" 4'-2 1/2" 2x4 stud wall/two (2)A31 w/2"support I� J • .nr, 2x105 Iy,�c,c• ts�n!N,►?-I�t „'�i <tjx}` I 4, ?.b,l Ft.7wl3FL' mull detail _ _.L..... N t. Notes: Finishes and Hardware to be selected by owner. I `' Q 6XT 6,PAPF- _ Qj pOf�1 D 9 !_ow, 7. I,R7 6, Nf—sc. t_....) L ......_.,...�.._......_ .. ...,..,.- F i �/ }, i !, Flo G ►JG'• is L6t) CONO"1Jf?,S 6- ,j FFZA i`rP• t 13o?I'6p.O F407GT F�� ��-�'.l�_1.1`fA�°-.N.� I:.� 7�� •• •- roc t • s I I t ' 1 i y iLI Lam. 3 J vf i z Al i 4 { J - O V o. O i s i { f ! I -a i Jt . 113 Lq , _ rt- E Eli i aI IF ► z li ii I I� t� a i - 4 Sly-. �us \ ALI �- - -- — - - - - - -� °t s i .. � .. •�-�!-w+�-..a Km: - n �w ebw+.-wi.- .. .r�en Ma•a1 a .. .,.ti. ice-. .•r..}+ .A. `� ..nnw. wr s £.S w�. �.w.-.. u u, .� ....+.-, r,. .- � 4 vr,.c.A"Y"..F t r UI I ! i Y -:7, , LOA IZ I - — — --- ------ - ® to i V7 �rt v: LU ILU .. � - .s.,_ •`�, 'r, - .- ... b i ,„.,Yy,A,y..vs.-.V. 4'w a.}•vxv,.. ^u"i.a �jf ew'+..rtiw �•*ip' 'r - r , /5c5l.IR F�q C P;Z 0 T C.���'�/ �7 �iL eV/��®��� V ����/►�! �A�t/NOL� .�/�lC� COG�E.� A /W A Z/ M,�,vNt�LE �'1�(/lf COUP e _ �OPD�F1� �11��S,lJlZF�9C�' ��,u/�9l'�' c�Y�ST�Il/J l/%=///,�=////-/� ° ✓7 �( % ��l//�/� �-/�f��E /l/= •6oleCK To ?ROE ✓7l0 �j�.•C4ST/eov ��D• 1...✓[-T 4�v, //,�F Alar /Ul/ - a.. /c,� L/Q v/O L cUEL e = JUU• O O c �• //01 j n 00 00 O ° �/ /� ,�/ /Or� 7" T/r ' G 00 00 oAllo , 1 Cocd/c. � s '1l/�ay�v�ro,v �sr. PE.�re,�o�E M��s. �/1�f//�J.y4 cfTov fir P7--1C /f�iV1C /// Feo,r J�ovs� 00000 00 00 O T-YgT Th�-- C(::2/v45/T/o1s Cs110xiv o v Ts//S �.Z xgAl -qeE ASS Ory TNT' 717- TWO 7b�AT T1,,- /A-/ \� ,4ccoe.aANC2E wiT4 TEE ,Z2AIIAq coil JEEF46�E 07- 1 V /GOD Lov ,ti ' _ •a C,� T/C T�,�.� rn A7 15 7 tV FP::?e' E�I.ST�rtJly c5W.,eFWC �L01 /—y' TEAT T.Y/S TEAS T XIA,5 Mowo E /.V AGC 0.2 OR�tIC� o�- �� THE 4�9.55. OcP- Of PUaL/C • /U,EL 1, y��4GTH A.VD 7.'�AT THE' ,�F.S•!J ` H,Z� Coee�c7" To TIDE B�"5 T Qoa ,Cfo 111�rEe Ruud :: �Z/2/