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HomeMy WebLinkAbout0766 MISTIC DRIVE - Health 766 Mistic Drive Marstons Mills A= 0i —071 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 766.Mistic Drive Marston Mills. MA 02648 Owner's Name: Tom&Joan Christo Owner's Address: ►"t�� Date of Inspection: June 7. 2007 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.:Box 49 Osterville,MA 02655-0049 ' Telephone Number: (508).862-9400 F 1 CERTIFICATION STATEMENT CD �W `-�• I certify that I have personally inspected the sewage disposal system at this address and that the in onnation reported-,;__ below is true; accurate and complete as of the time of the inspection. The inspection was perform 4ased on. y training and experience in the proper function and maintenance of on site sewage disposal systems:'= am a DYP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system a ✓ Pusses F: Conditionally Passes ds Further Evaluation by the Local Approving Authority ail Inspector's Signature: Date: June 14, 2007 The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies.sent to the buyer,if applicable','and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTI ON FORM-NOT FOR VOLUNTARY ASS ESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 766 Mistic Drive Marston Mills. MA Owner's Name: Tom do Joan Christo Date of Inspection: June 7, 2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,.as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or,high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 766 Mistic Drive Marstons Mills, MA Owner's Name: Tom&Joan Christo Date of Inspection: June 7. 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 766 Mistic Drive Marstons Mills, AM Owner's Name: Tom&Joan Christo Date of Inspection: June 7, 2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within'a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking.water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any 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 co nsidered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 of Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 766 Mistic Drive Marston Mills, MA Owner's Name: Tom&Joan Christo Date of Inspection: June 7, 2007 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE_DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 766 Mistic Drive Marstons Mills. MA Owner's Name: Tom&Joan Christo Date of Inspection: June 7, 2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 4 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped after the inspection for maintenance Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy . Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed on.8129187-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 766 Mistic Drive Marstons Mills. MA Owner's Name: Tom&Joan Christo Date of Inspection: June 7, 2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 6' Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 ,ag 1. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Coimments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.). Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs ofleakaze A riser was installed on the inlet cover. The cover is now 2"below grade The tank was pumped a ter the inspection for maintenance GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 766 Mistic Drive Marston Mills. MA Owner's Name: Toni&Joan Christo Date of Inspection: - June 7. 2007 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: Qallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -- 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.): The D-box was normal. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): S a 8 Page 9 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 766 Mistic Drive Marstons Mills, MA Owner's Name: Tom&Joan Christo Date of Inspection: June 7, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: _2-4'x 6'(600 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative system' Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): The pits had 2.5'ofliauid on the bottom There did not appear to be any s_ i-ens offailure A riser was installed on pit#4 to bring the cover 5"below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: _ Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 t' Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 766 Mistic Drive Marstons Mills. MA Owner's Name: Tom&Joan Christo Date of.Inspection: June 7 2007 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. a �.. FivnT 3v la . r 3c 410 y 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 766 Mistic Drive Marstons Mills. MA Owner's Name: Toni&Joan Christo. Date of Inspection: June 7. 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the mans were showing approximatelv25'+/-to ground water at this site. This report has been prepared only for the septic system and components described herein. ,This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 � 7y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 766 Mystic Dr Marstons Mill RECEIVED owner's name Walter Surniach ' Date of Inspection June 16, 1995 JUN 2 3 1995 PART A WAM DEPT. CHECKLIST TMoFBAFW$TABLE Check if the following have been done: /pumping information was requested of the owner, occupant, and Board of /Health. V None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. y/The facility or dwelling was inspected for signs of sewage back-up. __LZ The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. l-"*'The facility .owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8« SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents garbage grinder, yes or no laundry connected to system,, yes or no /✓ seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: ' Last date of occupancy GENERAL INFORMATION Pumping records and source of information: ADD A- L�- A/ System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Ty p 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information• !J Sewage odors detected when arriving at the site, yes or no q ♦ ' 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / SYSTEM INFORMATION continued SEPTIC TANK: v (locate on site plan) depth below grade: 1 a material of construction: _,,—/concrete metal FRP other(explain) dimensions: —l b z — G sludge depth ' `' .distance from top of sludge to bottom of outlet tee or baffle scum thickness G' distance from top of scum to top of outlet tee or baffle -distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) aA., e DISTRIBUTION BOX:y (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: t/ (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recomir:endations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : - ('-,/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number �_( PR C d i leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: • (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) ' J/ w 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landma ks or benchmarks locate all wells within 100 ' b yo` v � � p �y DEPTH TO GROUNDWATER ,,fj -' depth to groundwater method of determination or approximation: c 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of :2emination in all instances. If "not determined" , explain why not) Backup of sewage into facility?' " Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box- above butlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? /y less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform 'bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. TOWN OF Barnsf ahlP BOARD OF HEALTH ;f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 766. Mystic Dr Marstons Mills ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Walter Surniach PART D - CERTIFICATION NAME OF INSPECTOR W.E. Robinson SR COMPANY NAME W.E. Robinson Septic Service COMPANY ADDRESS P.O. Box 1089 Centerville MA 02632 Street Town or City State ZIP COMPANY TELEPHONE ( 508 ) 775-87-76 FAX ( ) CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported p ed is true , accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . jhe one: System PASSED The inspection which I have conducted has not found any information which - indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. V Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc ' Buyer; John & Nancy Crossetti /3 : TOWN OF BARNSTABLE 1i LOCATION ?N c���.D�. SEWAGE # ��'" 1053 VIU AGE /►n►llr, ASSESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. 1 SEPTIC TANK CAPACITY 5� LEACHING FACILITY: (type) a �Xc�� �•T (size) �sTML NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tablet Feet � o the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi'g facility)_ ) Feet Furnished by L 4 SOP- + n J FO f C, ' 1 GAr t FwnT 3v �a- t - yy S 3` yo O y TOWN OF BARNSTABLE �° /CO- — o-7/ LOCATION _ o'r► 7(D �Jz l J G '-Dpz ,__ SEWAGE # L 6— VILLAGE M A R37 a W S M f LLI(I ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.`�a h-w rj4mcFzi• SEPTIC TANK CAPACITY I,SoO R© LEACHING FACILITY:(type)_�--� �(size) L_') 6OO NO. OF BEDROOMS -3 PRIVATE WELL OR PUBLIC WATER L!1 BUILDER OR OWNE #VC DATE PERMIT ISSUED: /O -- s•- f DATE COMPLIANCE ISSUED: �3 ' � 9 VARIANCE GRANTED: Yes ,W No /'�/ rah � o� � �Z 2 �� CkF/00 COMMONWEALTH OF MASSACH ,S, `aka vos �i1't`+c � OARINS Ag� � EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIF�S nn�t ` DEPARTMENT OF ENVIRONME�1''LPFR M(ft-1f1 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 766 Mistic Drive Marstons Mills.MA 02648 Owner's Name: Joan Christo V Owner's Address: - Date of Inspection: April 20, 2005 - - U ..._.' Name of Inspector:(Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Ostervllle,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP t approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: April24, 2005 The system inspector shall sub . i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) i Property Address: 766 Mistic Drive Marstons Mills. AM Owner: Joan Christo ; Date of Inspection: April 20, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: t 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system,components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: I 2 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SU BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 766 Mistic Drive Marstons Mills.AM Owner: Joan Christo Date of Inspection: April 20, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 l E OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 766 Mistic Drive ' Marston Mills. MA i Owner: Joan Christo Date of Inspection: April 20, 2005 4 D. System Failure Criteria applicable to all systems: ; You must indicate either"yes"or"no"to each of the following for all inspections: t Yes No i ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/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— Any portion of the SAS,cesspool or privy is below high ground water elevation.- Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be'necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply . _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 !� Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 766 Mistic Drive Marston Mills. MA Owner: Joan Christo Date of Inspection: April 20, 2005 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 A. Page 6 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION Property Address: 766 Mistic Drive Marston Mills.MA Owner: Joan Christo Date of Inspection: April 20, 2005 FLOW CONDITIONS p RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 4 F Does residence_have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.). r Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in 2004-per owner , Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach"previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 8129187-tier as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r. Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 766 Mistic Drive _ Marston Mills. AM Owner: Joan Christo Date of Inspection: April 20, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 6' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage The inlet cover was 30"below Qrade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distancb from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as.related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 4 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 766 Mistic Drive Marston Mills. MA Owner: Joan Christo Date of Inspection: April 20, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 766 Mistic Drive Marstons Mills. MA Owner: Joan Christo Date of Inspection: April 20, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not,located explain why: Type ✓ leaching pits,number: 2-4'x 6'(600gaQ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The nits had 2'of liquid on the bottom. There did not appear to be any signs offailure. The covers were 30"below grade The bottoms to-arade were 13'. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 f Page 10 of 11 d• OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 766 Mistic Drive r Marston Mills. AM Owner: Joan Christo. Date of Inspection: April20, 2005 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. f i Rw-r 30 _ i L I 5� O ya, 3� y0 , I � y ' 4 I f , 1 • 4 10 / r V � Page 11 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 766 Mistic Drive Marston Mills. MA Owner: Joan Christo Date of Inspection: April 20 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 25'+1-to—around water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future.. There have been no warranties or guarantees,either expressed, written or implied,relating to the system,the inspection and/or this report. 11 g.: _ Cw11 C RRK w >. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALT1416 OCT -9 AM11 43 o1n.W...................OF.... A '5T.Aftt......_..__.........................---... ,Applira#ilan for Disposal Warks Tonstrnrtinn Frrmu Application is ereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal System at Location-Address o tre ss No. AMMFTI l---------------- r� .... .i�.r Owner Add W Installer Address Type of Building Size Lot.. 5,A0. -.Sq. feet U Dwelling—No. of Bedrooms..........................•-••_. -----Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ............................ No. of persons___.....___.._._..... Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. ... ... h W Design Flow.......5.5..........................gallons per person per day. Total daily flow---- gallons. $Y4 Septic Tank—Liquid'capacityl.2.50.zallons Length.10-Q7 Width.r..t'�n D"__ Diameter________________ Depth_.5. -1-_. Disposal Trench—No..................... Width.................... Total Length.........------. Total leachingarea....................sq. ft. Seepage Pit No......Z........... Diameter...1Q�'0`' Depth below inlet._,, !.'.���.... Total leaching area 62......sq. ft. Z Other Distribution box (✓S Dosing tank ( ) p- 5<Og5 aPercolation Test Results Performed by A ._. ...�ZI.AN1 _. tul `flllyDate__J.SlI�.._1C),_1.9$b__. Test Pit No. 1.._...�......minutes per inch Depth of Test Pit....�.4___ .__.. Depth to ground water........................ (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil... D� ! -...-�A.,U, P.......L? L0._��/ x V -•------------------------- ----------- --------------- ----------------------------- ---............. ---•-----------•-------..-----------•-•--------.--------------.------------•---•--•-------•- W U Nature of Repairs or Alterations—Answer when applicable.............................•..................._........._._.................._.._......._... ...----•-......•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITILj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued by the board of health. ..... ............................... --•..... .................... -- ?v Date Application Approved By........................ 1��-I..-�-- Date Application Disapproved for the following reasons:................................................................................................................ ...•..-•------•------•------•----...----•-•---------------------------------------•-------•---------...•..-----•---------•--------------------------•-•---------------------'................ C�9 Date j _.Permit No.---•--•---••---•-----•------•--•-------------- ---.. Issued_......................................................... Date low, Fss.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �Tc,W N...................OF...L.-2A V 0 5T�L� - Appliration for Disposal Works Tonstrnrtion Prrutit Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal ystem at ar �� Location-:Address �.. � . • AT-f M C 1 T t�Location 11 v G O N }� ��D .....-•----------------- ...--............ - -...... - .......................................... . •- .....................- owner Address W Installer Address VType of Building ii Size Lot..��.'.......1.��©._Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons........._._._.............. Showers ( ) — Cafeteria ( ) a' Otlrz fixtures -•-•--•.........•-••._...•- w Design Flow..........................................gallons per person er day. Total-dailyy flow........................................__._gal ns. WSeptic Tank—Liquid capacity D.gallons Length.1........ .. Widt .=O ... Diameter................ Depth..'.....�..... x Disposal Trench—.�To .................... Total Lenth..................... Width g ...,:.... Total leaching area .::.:___ ._ . sq. ft. � I U -O" :� i �"8�_------ Seepage Pit No..................... Diameter.................... Depth below inlet..-__...._._.._._._. Total 1 Ching area............__....sq. ft. z Other Distribution box (�) Dosing tank '-' Percolation Test Results, Performed b34'.n`P -._-C_-1- --N---- .L'Y1t�Il-iDate.`j..'. ........I � .... Test Pit No. I................minutes per inch Depth of Test Pit.......-............. Depth to ground water........................ fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil_. I ur ( ��fa+�l U rj 'L o �0 - x --- -•-----------••-••-•----....-•-•--••--•----•-•--....---•------••--------••----•--•-•-•-•-----------------•--...••-•-----•-----................--•-••.... 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee issue the,board f health. Date CSC Cam' :.... - ............................................ ................................ Application Approved B .................................. Date Application Disapproved for the following reasons: .........-•--------•-------------•-•-----..........--------.........--•-•-•---•---•-----•----•--•......-----•-•-•-•------------ c7 ----------------------•-----•----------•-•-•---••--- ----------•--- Date �r3 PermitNo-----------......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARP OF HEALTH ............. �Gl/! ......oF......... /1/ `7�/1�L .................................... Tntifirate of Toutpl attrr THI 0 CE T�IFy t the Ind;vi 1 ew< e Dis os ystem constructed (�Repaired ( ) ///G? y� 7,/ �IOC� Install i at........�. .....r-...-- ----------------------- ....-�_.� - ............. has been installed in accordance with the provisions of TIII& 5 of The State Sanitary Code as desf ribed in the . .....application for Disposal Works Construction Permit No..... .. ....f_ c1 ....... dated-----}J .�.' ?19=:_............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI�F CTORY. DATE............... .......•. . .....---•-----.----_. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOA. OF HEALTH / 1/............oF.. /,'/ '�..�11 ��........................................ ............... FEE........................ to 1 Works (911 #.rnr#uan ramit Permission i ereby granted- ,� it ............................................ to Construct ) or Repair ( ) an Individual Sewage Disposal System Street -- p-� as shown on the application for Disposal Works Construction Permit Dated Dated.._._.'. /.:- ........... = J Board of Health " DATE..... {•• ---•••••--•----•--•.......................................•---- FORM 1255 HOBBS & WARREN, INC:;"'Z�BLISHERS �' ,___-L I I_ I I iI I I ! , .9 I ----------- "I 11�F­l_ - ­ 11 I I I ____­­ --I____ _­_.l____.­_______­___­__ -�-"---------�--�--------�-�----- I I I � . 11 , " . , , I _____ illilillill , __ , _ - 11 � 'N'­ " , ,- , _", ',�� . lTyl;XU 0 _; -,�'lv��,,,;*�_w�w�,'_' ,V,, �-11, I ,,�A ... .. 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