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HomeMy WebLinkAbout0015 NELSON LANE - Health 15 Nelsen Lane Marstons Mills A= 126— 074 r is(a--o4-� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;: 15 Nelson Lane G Property Address I �� Jeffery&Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/201,7 page. City/Town State Zip Code Date of lia pection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 's a3 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection r� Company Name 74 Beldan Ln. rem Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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. 5/12/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Nelson Lane Property Address Jeffery &Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 15 Nelson Lane Marstons Mills is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 4 Infiltrators. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 �. Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 15 Nelson Lane Property Address Jeffery &Allison Marshall Owner Owners Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. City/Town 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Nelson Lane Property Address Jeffery &Allison Marshall Owner Owner's Name information is required for every Marstons Mills . Ma 02648 5/12/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Nelson Lane Property Address Jeffery &Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 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 ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts F v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M .'y 15 Nelson Lane Property Address Jeffery &Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Nelson Lane Property Address Jeffery&Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. Cityfrown 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Nelson Lane Property Address Jeffery &Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach.a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M ' 15 Nelson Lane Property Address Jeffery&Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 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: System repaired, unknown date Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 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 gallons Sludge depth: 61' t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 15 Nelson Lane Property Address Jeffery &Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, tookmeasurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Nelson Lane Property Address Jeffery&Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 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 a 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 9 p Y rY 15 Nelson Lane Property Address Jeffery &Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 15 Nelson Lane Property Address Jeffery&Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ 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.): Leaching facility was video inspected from d-box and was found to be functioning with no sign of past hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 15 Nelson Lane Property Address Jeffery&Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 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 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Nelson Lane Property Address Jeffery&Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 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 G Q6 1 A � �3 t Mo ,42 13� _ _ 2 �►3 � b ,33 S7'(' AY Lto CLl t5ins•3/13 Till 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M y 15 Nelson Lane Property Address Jeffery&Allison Marshall Owner Owner's Name information is Marstons Mills Ma 02648 5/12/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If� checked, date of design Ian reviewed:' g p 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: p You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M " 15 Nelson Lane Property Address Jeffery&Allison Marshall Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/12/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to Ali 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 l 6 • • • ,: r — ;s Legend •" r + • + ; _ _ �„ 13 Zoning Districts Saltwater Estuary Protection #'1338 F Parcels Town Boundary Railroad Tracks Id Buildings Painted Lines #450 Parking Lots d Paved #1360 P unpaved Driveways "A�f.. � r' 0 Paved �{ P Unpaved 493 Roads M Paved Road #356 0 Unpaved Road 459 r 13 Bridge . ■� Paved Madw~ #A45 34 Streams r Marsh _ apt t A Water Bodies 76 #A 5 F A 'mot k #51 tGtA ( # 27 #59 # #1275 #83 ,y 112r7 ! 0 N. #150 '• 62 `� 49 MOD - Map printed on: 5/31/2017 This.nap is for illustration purposes only.itis not parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA o26oi O 167 333 n on-the-ground survey.It maybe generalized,may not a umle rrhati..hips to physical objects on the map 5o8-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale:l inch= 167 feet O cartographic errors or omissions. gis@town.barnstable.ma.us r 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 y t Property Address: 15 Nelson Lane Marsions Mills,,MA 02648 Owner's Name: Andrew Lockhart Owner's Address: Date of Inspection: Swtember.9, 2009 Name of Inspector: (Please Print) Jantes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the'inforination reported below is true, accurate and complete as of the time of the inspection. The inspection was perfonned 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 cn nditionally Passes 4 a N ds Further Evaluation by the Local Appro�Vji>, Authority �n Fai sPO tr Inspector's Signature: Date: Se tenor r 17 200 The system inspector shall su it a copy of tl is inspection report to the Approving Authority Joard of Ilth o DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow o 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 1 � Page 2 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Nelson Lane Marstons Mills, MA Owner: Andrew Lockhart Date of Inspection: September 9, 2009 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 deten-nined",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 oi•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 NO explain: 4 2, Page 3 of I l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Nelson Lane Marstons Mills. MA Owner: Andrew Lockhart Date of Inspection: September 9, 2009 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 ti Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Nelson Lane Marston Mills, MA Owner: Andrew Lockhart Date of Inspection: September 9, 2009 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 11 of a public water'supply well If you have answered"yes"to an. uestion in Section E the system is considered a significant threat or answered Y Y any Y g "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 s stem owner should contact the appropriate re ional office of the Department. g YP 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 15 Nelson Lane Marston Mills, MA Owner: Andrew Lockhart Date of Inspection: September 9, 2009 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) [3 101 CNIR 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: 15 Nelson Lane Marston Mills. MA Owner: Andrew Lockhart Date of Inspection: September 9, 2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 7 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 year's usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.):' Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary.waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: unknown Was system pumped as part of the inspection(yes or no): If yes,volume pumped: - - gallons--How was quantity pumped detennined? 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: Date of installation 12114199 per as-built card Were sewage odors detected when arriving at the site(yes or no): No t 6 Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I S Nelson Lane Marston Mills. MA Owner: Andrew Lockhart Date of Inspection: September 9, 2009 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: 9" Material of construction: ✓ concrete _metal fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffler 30" Scutn thickness: 8" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 101, 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.). Cement tees were present. .The liquid level vvas even with the outlet invert. There did not appear to be any signs�s of leakage 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 l Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15 Nelson Lane Marston Mills. MA Owner: Andrew Lockhart Date of Inspection: September 9, 2009 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 normal 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: 15 Nelson Lane Marston Mills, MA Owner: Andrew Lockhart Date of Inspection: September 9, 2009 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 4 Infiltrators 11'x25'per as-built 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 inTltrators had 4"of water on the bottom. There did not appear to be anv signs of failure.A camera ivas used for the inspection. 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 I f Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15 Nelson Lane Marston Mills, MA Owner: Andrew Lockhart Date of Inspection: Sotember 9, 2009 SKETCH OF SEWAGE.DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. C ti 6 A 3 y a c,y i g 3 ao 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: 15 Nelson Lane Marston Mills. MA Owner: Andrew Lockhart Date of Inspection: September 9 2009 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 60+/- 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 contozirs 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 reaps the maps were showing approximately 60,+/-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 ivill function properly in the fixture. 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 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION PARCEL . 017 + TITLE S LOT OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION j r•_, /S �rre Property Address: h-e Owner's Name: Owner's Address• �' o -0 C"Date of Inspection. Name of Inspector. leae gria p �r / o%{g��• � � Company Name• Mailia�.g Address: Telephone Number: 30� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this addr and that ess below is true,am me and complete as of the time of the' information reported training and experience in the Proper function and maintenanceinspection.The inspection was of on site sewage dis performed based on my approved system inspector pursuant to sec ti .340 o e S(310 CMR 15.000). l systems. I'am a DEP Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: - a �� Date: The system inspector shall submit a copy,of this inspection report to the DEP)within 30 days of completing this' sY Approving Authority(Board of Health or gpd or greater,the• unspection If the stern is a shared system or has a design now of 10,0 inspector and the system owner shall submit the report to the appropriate regional otI'ice of the DEP.The original should be sent to the system owner and copies sent to the buyer,if a licabie,and the authority. / /� y pp approving Notes and comments Ta h Ir needs OH r7 1 h � � �/'�G►"•fie"Ah�e *""'This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not conditions of use. address how the system will perform in the future under the same or different of use. ` Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /-.> G.to✓t L,g� °. Owner: �0q4 axf PF Date of Inspectioe; a 3 Inspection Summary: Check A^C.,D or E!AL&AVAcomplete alb of Sectioa D A. SG/ ysye�i Passes: I have not found any infprmapon which indicates that any of the fail 15.303 or in 310 CMR 15.304 esist Any failure criteda not evaluated are. u�criteria described in 310 t�11�IIt indicated below. Comments: & System Conditionally Passes: AzQne or more system components as described in the"Conditional Pass" repaired The system.upon completion of the section need to be replaced or ` replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(y,N,ND)in the explain for the following statements.if"not determined'°please The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurauy unsound,exhibits substantial infiltration or exfilt mtion or tank failure is imminent.System will existing tank is replaced with a co pass inspection if the *A metal septic tank will � septic tank as approved by the Board of Health. indicating that the tank is less than inspection00 years old is a suuctuzlle.IY�1'not leaking and if a Certificate of Compliance ND explain: Observation of sewage backup or break out or hi obstructed pipes)or due to a broke Ph stable water level in the distribution box due to broken or approval of Hoard of Health): n' �or uneven distribution box. System will pass inspection if(with 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 pass inspection if(with approval of the Board of Health,); y due to broken or obstructed pipe(s).The system tivill broken Pipe(s)are replaced Obstruction is removed ND explain: c �� C7� Page 3of11 OFFICIAL INSPECTION FORM.NOT FOR VOLUNTA ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION RY I1�SPECTI N PART A CERTIFICATION(corjn, Property Address: S B&'00 GG„� Owner: ar,H� f N /g . ©d 6 v.`.. Bate of fnspecEioe: C. Further Evaluat3oo is Wired by the Board of Health. �CondtiQas exist which ire is failing-to pow�t ��n'a�ent the Board of Health in order to determine if the system 1. System will pays unless Board of Realth'determines in accordaoee_with 310 '� CMR M303 — — system- -— fimctaonmg-iia 9 der wlaicbiv�ll- - - -- - (1)(b)-that tfie --- - - --- Preted publlcAenith,-safety and theeavirsaoents. — Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a vegetated wetland or amarsh snit Z•. Sy.'tem will fail trnleyy the Beard of Health(and Polillc�Water Supplier,if an system is funs 8 m x manner that protects the Public safety sad enviironment: ney that the The system teas a' _ , surfaceseptic tankard soil absorption system(SAS)and the SAS is within 100 feet of a supply os to a surface water supPly. The system has a selnic tank and SAS and the SAS.is within a Zone 1`of a stem .. _. public water supply. I'he.sy has a septic tank and SAS and the SAS is within 50 feet of a private w The system has a water supply well. .septic tank and SAS and the SAS is less than 100 feet trot So feet or more from a Private water supply yyell•s.Method usedlo detenwile distance **Tms system passes.if the well water anal sis, Y perform na and volatile or�c compovadsin�catwen DEP CWified laWratory>Is for Goliform the Presence of ammonia nitrogen and nitrate nitre en is ° �f Pollution from that facility and failure criteria are�Wered.A g equal to or less than 5 pin,Provided that no other copy of the.analysis must be attached to this form, 3, 9ther; �l page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:- J S' OyJ \ Owner. , f/� Date of Inspection: D. System Faihrre Criteria applieabk to all systems; You must indicate`yes"or"no"to each of the following for all inspections: Yes NV bap of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ — D'ggW S or or cesspool g of effluent to the surface of the ground or surface waters due to an overloaded or — �ogged SAS or cesspool c liquid level in the distribution box alcove outlet invert due to an overloaded or clogged SAS or -- VOl dePthquid in cesspool is less than 6"below invert or available volume is less than pumping more than 4 times in the last 2 day flow of times pumped Y NUT due to clogged or obstructed pipe(sj.Number — -!E!- l ion of Cesspool o of the SAS,ceSSPO01 or�is below high ground water elevation. water Supply. �'S' within it)n feet of a surface water supply or tributary to a surface _ d�rtion of a cesspoot or privy is within a Zone i of a public well., portion of a cesspool or privy is within 50 feet of a private water supply well. Any porttort of a cesspool or privy is less than.100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system Passes if the well water analysis, Performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) (Yes/No)The system tom,I have determined that one or more of the above fait ure criteria c�dst as described in 310 CMR 15.303,therefore the system fails.The system owner should conw 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 now of 104M gpd to 15,009 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) xd e system is within 400 feet of a surface drinking water supply esystem is withitt 200 feet of a tributary to a surface drinking water suppi_y e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area 1WpA)oramapped Zone it of a pubtic 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 h�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 CUR 1.5.304,The system owner_should contact the appropriate regional office of the Department. i Page 5 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ,o/ CHECKLIST Property Address: ti&100 Go-n� Owner. �..a) e or °� Date of Inspection: J Check if the following have been done.You most indicate es"or"no"as to each of the followin . Yes o information was provided by the owner,oa;upeont,or Board of Health Were any of the system components pumped out in the previous two weeks system received normal flows is the previous two week period iarWwk mes ofwater-been mooed to am system recently or as part of this inspection West as built plus 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,exdudibg the SAS,located on site �o Were the septic tank manholes un�,ereq open,and the interior of the the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and dept Inspectedhf sc coum &-'. — Was aft owner(and occupants if different from owner)Provided with information on the proper sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined Yes mq � based on: xastmg 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 CUR 15.302(3)(b)] 7. r page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: LS-1166,00 G.a•+� r: L. 8at,C<,-6 Owne Date of Inspection: U.MIDENTIAL I O CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): 3 File DESIGN flow based on 310 CAat 15.203(for example: 110 gpd x#of bedrooms): .��-b /3vlj� Number of current residents: -2, Does residence have a garbage grinder(yes or no):.," Is Ia:mchy on a separate sewage system(yes or no):I [if yes inspection' Launcky sysysteminspected(yes or no):� _ spection required] Seasonal use:(yes or no):Iv o Water meter readings,if available past 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: Ct^/,tN COM MMCIAL/INDQSTRIAL Type of establishment: Desiga flow(based on 310 CN R I5.203): Basis of design flow(seats/persons/sgR,etc.): Grease trap present.(yes or no):_ lndostrial waste holding tank present-(yes or no): Non-sanitary waste discharged to the Title S system(yes or no): Water meter readings,if available: East date of omapancy/use: OTHER(describe): Pumping Records. GENERAL INFORMATION Source of information: /GO•- l° Was system � If yes,volume Pint of the inspection(yes or no):" Reason for P� _ Puons-How was quantity pumped determines F SYSTEM -_- tank,distribution box,soil absorption system —Siqgk _Overflow cesspool Privy _.Shared system(yes or no)(if yes,attach previous inspection records,if any) InnovativelAhmnative technology.Attach a copy of the current operation and mamtenance contract(to be obtained from system owner) —Tiles tank _Attach a copy of the DEP approval _other(describe): Approximate aE of all components,date installed(if known)and source of infomion: Q n Were sewage odors detected when arriving at the site(yes or no):�/D L _ �j Page 7 of I I OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /ve1so owner:�� Date of inspection. BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction Distance from private wa mon PVC other(explain): supply well or suction line: Comments(on condition of joints,venting,ewdence of leakage; ):etc. SEPTIC TANX- (loc ate on site plan) Depth below grade: Material.of motion: —mew. �_polyethylene --off ) — If tank is metal list age:_ Is age confirmed by a Certificate of certificate) J X Compliance(yes or no):_(attach a copy of Sludge depth:Distance — to bottom of outlet tee or baffle: Q Distance from top scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of et tee or baffle: How were dimensions determined: A �A s 2v�c.e Conk(�pimping recommendations,inlet and outlet tee or baffle condition,structural Of I as related to outlet invert,eviddence �e integrity,liquid levels etc.): / a.nl�,- NeG'Cl Ood try o%7�roh /�O L,Pq Gam 'Tip✓v(locate on site plan) Depth below grade: Material of eonsttuctim-:—concrete (explain): —' —fiberglass--�ethylene—otter Dimensions: Scum thiclmess:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom Of scum to bottom of outlet tee or baffl Date of last pumping Comments(on pumping recommendations,inlet and outlet tee or baffle condition, as related to outlet invert,evidence of leakage,etc.): integrity, liquid levels s Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property address: S c1,eo 4.,,,� w oner: 001 6 Date of Inspection: p TIGHT or HOLDING TANK:�t�must be pumped at time of mspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyeklene other(explain): Dimensions: Capacity: Deign Flow: Alarm present(yes or no): Alarm level: Alarm in working order(yes or no}: Date of last pumping Cormments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:ZL/of 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.): PUMP CHAMBER locate on site plan) Pumps is working order.(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and a ppurtenances,etc.): CJ 5 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: xe o m /—.a Owner. Lar HA- Date of lopectio . 0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) if SAS not located explain why: I Typeleaching pits,number � Y17 � �T 0 rl L✓ � leaching ebambeM mmiber: / �f S40n leachraggalleries,number: leading trenches,number,length: .7 de leacbingfields,number,moons. overflow cesspool,mmmber: innovativelalternative system 'IMpe=w of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, mac) 4 h rC S I C�po0 0 ,i 11 CESSPOOLS: cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimueM property Addrew -;, /*IC/ 0 o Z—G A e, Owner: !^414 o '/ oe Date of Inspection: ? pY SKETCH OF SEWAGE DLSPOSAL 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 buildin& a f ` o1cf/ AF -�' a3 - 3y " , 1413- 3S Page 11 of 11 QFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimxd) property Address: 1-5 Ale/so 0 `o4-e, Owner. Laf►t� Date of Inspection: g d3 4 SITE EXAM. slope surface water Check cellar Shallow wells Estimated depth to ground water°�y 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 thin 150 feet of SAs) ./Checked with local Board of Heald}explain: M0 5 x G� Checked with local excavators,installers-(attach documentation) `!d• Ca-,4o►�-- Accessed USGS database-explain: K You most descrile how you established the high ground water plevation: 60 0 0 9• /pw �..etc . 4o!7'�''+ o� o✓a Aw .ram{ •�f-O�J ,� o , n C. ov-e 1 o," of 6t4cje _ _ opt % ` O 00.0 �� 1 !. Ur ,00C 91 l l/649 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Svstems Only. _ CERTIFICATION OF SKETCH AND PPLICAUON FOR A DISPOSAL WORKS CONSTRUCTION PEIMIT (WITHOUT DESIGNED PLAYS) I' �-A5 herebv certify that the application for disposal works construction permit signed by me dated concerning the property located at I 's H �0.SOiy I AwrZ_ &A'CS meets all of the following criteria: "• The failed system is connected to a residential dwelling uses associated with the dwelling. only. There are no commercial or business • The soil is classified as CLASS 1 and the percolation rate is less Chart ore equal to � minutes s per Inch. �Tnere are no wetlands within 100 Feet of the proposed septic system Where are no private wells within 150 fee;of the proposed septic system There is no incense in flow and/or change in use proposed There are no variances requested or needed_ Z The bottom of the proposed leaching facility will not be located !ess than five feet above the dtnum adjusted groundwater table elevation. (Adjust take groundwater table using the Frimotor ethod when applicable) • If the S.A.S. will be located with 250 fee;of any vegetated wetlands. the bottom of the r leaching facility will not;t located less than fourteen 1� fee; proposed ( ) above the maximum adjusted °roundwater table elevation, Please complere the rollowing: A) Top of Ground Sur ac=c-'.evadon(using GIS information) B) G.W. Ele/acian �.Q_the�L�X. Eiigh G.W. Adjustment _ `-i� DME—ERFNCE BETWEEN A and 3 � • SIGED : , DATE: (Sketch proposed plan of 5wsem an back]. q:health(older ccrt . II V ,, TOWN QF BARNSTABLE LOCATION J ( uc.Is�� r�� SEWAGE# `VILLAGE IM. M, ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY r LEACHING FACILITY:(type) T i r/a b r S (size) NO.OF BEDROOMS 3 OWNER loukkArl PERMIT DATE: COMPLIANCE DATE: Separation Distance.Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching:facility). , feet FURNISHED BY /1.S IQ117 DeN FDr J pi' D� ti A 3 ✓� Q 5� � I y � 8 a c,y 3 ao TOWN OF BA STABLE { LOCATION �S /�'► SEWAGE # 9?-IN, VILLAGE IS' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 12710C-4a.0 Zi� 27 Fr- O G�h SEPTIC TANK CAPACITY LEACHING FACILITY: (type /Al (size) NO.OF BEDROOMS / n BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: �t' Separation Distance Between the: Nfaximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells.exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �r — se) i i Y i TOWN OF BARNSTABLE LOCATION �� �� �� - SEWAGE * ` II,LAGEM1113 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /Y1�.0.. �-� i C'_ 72 &- O 6,:1 SEPTIC TANK CAPACITY LEACHING FACILITY: (size) NO. OF BEDROOMS n BUILDER OR OWNER / PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site:or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 306 feet of leaching facility) Feet Furnished by t F A 2-; 13 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computes Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplication for Mtopozal 6pztem Com6tructton 3permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System individual Components Location Address or Lot No. IA N t�.� tV�3'" 4 Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1 � o� (� S L PA\8 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flower gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank x Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) a_ T ` "" �%?" � -��- �_Ca C�k.G{` ,, -r.•t -c Cr ��ri ub rtf t e Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance hasz, n issue oar lth. — _ Signed Date ;,14.. 1 Z Application Approved by Date/?^t!j Application Disapproved for the fo lowing reasons Permit No. Date Issued No. 7 : t .r Fee _ THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) L1 Complete System Xindividual Components Location Address or Lot No. /'j t� (�' rV Val. , Owner's Name,Address and Tel.No. Yf Assessor's Map/Parcel ' —D—1 S C �A l ko Aj Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder.( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures .. Des#gn Flow gallons per day. Calculated daily flow �Cl gallons. Plan Date Number of sheets Revision Date Title ' Size of Septic Tank Type of S.A.S. t�•S Ct/Jc c i�+__ ��<<' Description of Soil , U A VZ S Air/9 _ _ Nature of Repairs or Alterations(Answer when applicable) 77cH--c-T Ai Cru (2 h GiT`L► QD6,,�--<L d!r o025- t1d tF f STG{-,re' c//J r-f /yf( Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate,of Compliance has-beEfor ms Ted-by-ilii. bar lth. 11 Signe _ Date d `� Application Approved by Date /- Application Disapproved e fo lowing reasons Permit No. - Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS v Certificate of Conmpriance THIS IS TO CERTIFY,that the On-site-Sewage Disposal System Constructed( )Repaired) )Upgraded Abandoned( )by - C / .": �, Cl a f .,I . at " KZ_C-S 0 & `l ha been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. t dated " 'Installer °� Designer The issuance of this permit shall not Ve co,s ed,�j a guarantee that the systter wiwill function as designed.r - Date _ Inspector 1_ ri4 - No.��- 7 �7 ---------------------------Fee �r)THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 30iopogai 6pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(VI-A--bandon( ) System located at iG S �/j. r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: - 1 1 �/ % Approved by 1/6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH Ai D APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit sinned by me dated conce ninQ the A property located at "� �LSp� I AVM_ vQ�C� meets all of the following criteria: `.• The failed system is connected to a residential dwelling only. There are no commercia l or business /uses associated with the dwelling. • The soil is classified as CLASS l and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within !(,';0 feet of the proposed septic system /T'nere are no private wells 1.vituin 150 feet of the proposed septic system There is no increase in -?ow and/or change in use proposed There are no variances requested or needed. Th.e bottom of the propose-' leciung facility will not be located less than five feet above the Mwdmum adjusted groundwater table elevation. [Adjust tl`ie groundwater table using the Frimptor ,,,/ethcd when applicable] • If the S.A.S. will be ':ocated with 250 feet of anv vegetated weuands, the bottom of the proposed leaching fat lity ;;,-ill riot be located less than fourteen !�) feet above the maximum adjusted goundwater table e!evauon, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ' , hZ `(B) G. V. cle�aion IV•®�the�L� t -ig . V. � b o O ` D>F"r ERE CF E t-FWEE�'A and H SIGNED : 1 • DATE: x (Sketch proposed plan of System on bath). q:health folder.c?e {«C�� ` �.. ..._r 4 } �,. � � � D •-4'. L Zt / 7 _ Ll--1 L O CATION S WAGE PERMIT NO. VILLAGE C�4 - pfy q ys V/p I N S T A LL R'S NAME i ADDRESS �-C4 y)I B U I L, E R OR OWNER J v)-n z7,s d. ec -,7, )1&y-L -DATE PERMIT ISSUED --7 S— DATE COMPLIANCE ISSUED r 1� ----------- 3 ��e � ��._--�' -''� .' � a d` ��' '� o �, �- 3 4 . � � l� � : �, __J ., .��. - k. ���. P2 No.--•-.---•• ��� ....................... ... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Applira#ion for Elhgpvnal Mirkti Tnmuur#inn Vantit App �`''n/ is ereby`�a—dee for Permit.to Construct or R� air ( ) an Individual Sewage Disposal System a J _ . . ............ -- •• . --•-•................-•-••--- ......................xol_z/-................................................. ocation-Address or Lot N ) ?-�--��.-�----------- Owner Address r — Installer Addres� Q Type of Building Size Lot..._ +rSq. feet V Dwelling—No. of B ........ ............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other t- es ---•-•---•----------•-•---- _._ -------------------------------� ---�'---•-. DesignFlow......... _ _gallons PerPerson per day. Total daily flow ..__._._ gallons- . __ --__ "P4 Septic Tank—Liquid ca acity� gallons Len th_ . Width__� . Diameter______.•-------. Depth-�� Disposal Trench—No.-------------------- Width.................... Total Length-------.... ....... Total leaching area....................sq. ft. Seepage Pit No----�__._____._-- Di eteva.o.___. Depth beAl w inlet___ �� Total leaching area ` .sq. ft. Z Other Distribution box (� Dosing tank ( ) C�r 670 �''r'��0�Z/ '—' Percolation Test Results Performed b}L�� /;�Q - r .. ----. Date �/ i '-�-•--- a Test Pit No. 1.__ _"Zminutes per inch Depth of Test Pit--/ �y�l..®Depth to ground waterer_�-.-____- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_____-____-_--__-_____. ---•------------------••-----••---•-... -•--••7....---------•--------..........---•-••--••---•••---...-------� ......----------...-------.----- a 0 Description of Soll--�---------���-�----�L��f=`-�_-r_��1�-`-��--�—�--�-�-•--•--�t---�`�----•�.-- -•--�--�-- ��.�--�-----•i ar _4 ------------�®---- ........................................... VNature 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�i:L<� p 5 of the State Sanitary Code—The undersigned further,agrees not to place the system in operation until a Certificate of Compliance has bee iss d by the board o health. /�//, "'• ` Da e Application Approved By....... --•• --•..------ — ----------------------- ` Application Disapproved for the following reasons:_____ .__ ---•----------------------•---•-•------....--•-------•-•-----.....----•------•--.._•...----••--------------•-------------•••----••••--------•----------•---------•--•---------------- Date PermitNo......................................................... Issued.---- 1 - ------------------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��/�✓...........OF AS 4.1t -./... _ .................... Appliration for Diopooal Worko Tomilrurtion Prrutit Application is hereby made for a Permit to Construct kf or Repair ( } an Individual Sewage Disposal System at: ell ...... ..................... -----_---------_1-----l ----------- ------------ Location-Address Lo ..._ a.... ter.- -------------- �:. c �:�......c._� , ram ...r . may es a a_... Installer Addree Q Type of Building Size Lot._ G-_Sq. feet Dwelling—No. of Bedrooms.........3.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ....................•--••--... -- WDesign Flow........i�.........................gallons per person per ay. Total daffy flow_.._.�a:�a�' ....................... 1�s. WSeptic Tank—Liquid capaciV.C.2 C?.gallons Length__-.-_.... Width ZK--:-... Diameter.---_-__•___-.-- Depth, x Disposal Trench . No. i.............. s ................. Total Length.._...._. �____... Total leaching area....................sq. ft. T ._..___=" Di mete,>��-�__-C 4... Depth t_ _ Total leaching area___�_�.--��--• ..sq. ft. Seepage Pit ?�o... -.,- �f ,�,� z Other Distribution 'ox K✓�I Dosing tank ( ) ftb Percolation Test Results Performed b-yD d.?:,"'nnlL1.�,i'!t - r fC �.���......----- ----- ---------. Date-----------------•-------- `�a Test Prt No. 1__,. .:79. -minutes per inch Depth of Test_Pit l�.* Depth to ground water-A---/__ .....___.. Test Pit N3. 2................minutes per inch Depth of Test:Pit.___._..,........... Depth to ground water........................ O Description of Soil.?'__-'. - ,Gj- '✓ - (/ _'Jr" G c�... ..........................Moml......... _. x U �c= � -' --•�. rt=-_.S�•c.1-� -- ......................./ � ' W 'c'7`�/7 tea 'I d J L ��.�t�'t? G- �' ,.- ---------------------- 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 b n i ued by the board f health. ' Si e ------ Date ....................... Application Approved BY ` � 4 ----------- Application Disapproved for the following reasons-----..............-•-•----------•---•----•-----•••---•------•-----•---•-•----••--•--•-•--•------••--......---- •-••-•---••-•-•---•-----•--•-•--------•----•-•-•-•-•---•-••---•---•--••------••-•----------•-•--------••...•-----••---•-----••---••-----•--•-•---•-•----•-•••••••--------------••-------•---••-•--•------ Date PermitNo---------------------------•---------------------------- Issued....................................................... Date 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......:.oF... l.!................. ............... ..., Qwertifirate of Toutplianre THIS I TO CERTIFY, That the Individual Sew,a Disposal System constr cted G")or Repaired ( ) ....................................-� i7- . _Cam/ � -------_.... at _.±!-n f — Ins j1J has been instalfed,.in accordance with the provisions of 7. 5 of,The State Sanitary o e d�sczibed in the a application for Disposal Works Construction Permit No._---__•.__ _�__-_______________________ da.ted___..-_-._.-.-------___._"---------------______--- "� THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. _/1 '5^0 DATI? -•------------•--•--•--•................... Inspector.. --------------------------- THE COMMONWEALTH OF MASSACHUSETTS t. BOARD OF HEALTH /...d..:�................. . ............OF..._/�}i fZ ...,.� / ,.� FE d....��...: �io�rv,��1 orko Cno�to#r�#ion r�rmi# � Permission is hereby granted../)Z?_.-�-'-'-'-`"- ....-.....4 t om / _... /G✓.......................................... to Construct..,('�—,);,.or Repair ( an Individual Sew e D'Sposal S stem 751K,/7 CA ... ti Street 2' as shown on the application for Disposal Works Construction mit o.✓_ .... Dated.* �� Board of fIealt DATE....................----------------------------------------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS v7 • _ _�--- . ; . . I /Fence 13i 17 Fe Vic e. ,_0 AZ C.FRTIf I E D4 PL* 0T PLA N :-O;C AT 1 o N: /ylr9.�5To�.+�S /yJilGs /yjigss , F:o:R • ;Ioegv CAL E: ~' 5op DATE: JU'v� �3 /980 :R-E.F E R. E N C £ w A./ D A T E 1�" H-EREBY CERTIFY . THAT THE BUILDING / . ���� ' SHOWN ON. THIS PLAN IS LOGATEp ON REG. LAND SURVE OR THE `-G R' OUN D AS- SHOWN HEREON, tN OF A1gS�; 105EPr li MQt4fiA#i.1R. i - �' � J .: M. MONAHAN, J 13d64 R . & ASS -OCIATES �o R.EGiSTERED L-A-.ND SURVEYORS & ENGINEERS �' �as u b51 MAIN STREET DENNISPORT� MASS. 02639 . I I � . -1 . I . . - I. I,�. I ­ I . . � I, I 1 Z,R"',�q,`�I,,�;..,�_�4t,, ,� --,I. ;. ,.� - �I;,,.,�, 4,�,..��",:,,1 .. :�, ��­_�I .:%�I:v'I c:�;'".!. ",��t, _,r:�', -, '.�,.--,��-ll 7.�,".. . - ,i I,, ,��l�;,�==__ ,I .�._��­­�,,__�.�, ,,:"4,:: , , � � I I I . I � ", .,,. ,"', ,. I.",:'. �.. . , , _� 1,, .,�,,%, . . ''. _. I ­71- 'I", - - - � . , 11 i, � � , �,",. , , ,� I , � . ,� . ,. - ".,, - ., . .1.., ��',�*� . , � I - - . �,. �, � - . . I I I�,�-�I '.�,,� 1, ,., I - � I I I " ._ I . .. I I......; . ,,.. ,.__%.­, . - .111- a ,";_.� n -J­. , _ 1. I I I 1, I _.jS��,�;�-.. .1. . p 1 4 1 � I - __-­_,�- "I I � ,� - ,� ,, I,�:;-,�-1 ,., ,�.... -, !.. ..�,� I-­z � . . . '.�,;��t.;, ,. "'��"--.. I . ­. ,.,,- , � , �.". I I � __;__-_,�-__ ,_-,__.__-"� - � � , . � . - ,lz , �� �� ��v`" .� y.1-i 1., �� , , - . -I I ,� ��_,�-, , .4 I . -". 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