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HomeMy WebLinkAbout0280 MAIN ST./RTE 6A(W.BARN.) - Health 280 MAIN'STREET ` West Barnstable A = 134 -'009 - 001 Commonwealth of Massachusetts _ _Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town . - State - Zip Code Date of Inspection = Inspection results-must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: -- - (N key to move your cursor-do not Ricky L. Wright. I J use the return key. Name of Inspector B&B Excavation Company Name VQ 14 Teaberry Lane " Company Address Sandwich Ma.: 02644 City/Town State Zip Code (508)477-0653 S14595 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 El Needs Further Evaluation by the Local Approving Authority 12/16/13 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: ubsurface Sewage Disposal System•Page 1 of 17 � 7 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 280 Main St. Property Address Tracy Sullivan ' Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 19,000 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 Secton 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. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts . _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 280 Main St: s Property Address Tracy Sullivan Owner. Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. - Cityfrown - 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 ❑ 0 Were-any of thasystem 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? Z El Were as built.plans of the ystem:obtained and examined? (If they were not available note as N/A) ... ... ® ❑ Was the facility or dwelling inspected for signs of sewage back up? 1Z El 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 ® El :::approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System.Information Residential.Flow Conditions: Number of bedrocros (design); Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 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 �M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. 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: 1500 gal. Sludge depth: no sludge 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 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour 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.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): At time of inspection d-box appears to in working order no sign of deteration, or carryover. 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.): I * If m r I pumps o alarms are not in working r p p o g 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M •''v 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ ileaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ Veaching 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.): At time of inspection leaching appears to in working order no sign of hydraulic failure.Leaching was dry at time of inspection. 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 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 corstruction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection . Form a Subsurface Sewage Disposal System Form -:Not for Voluntary Assessments 280 Main St. Property Address ..... ....... ..... Tracy Owner Owners Name information is required for every W.Barnstable Ma, 02668 12/16/13 page: City/Town State Zip Code Date:of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system; including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: and-sketch in the area below: El drawing attached separately 8 C3 - 3i - O :A 9c�rc�c�e t5ins•3/13 Title 5 Official Inspection Form:Subsurface:Sewage Disposal System-Page:15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is W required for every Barnstable Ma. 02668 12/16/13 page. CityfFown 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: >156" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. 1/28/85 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 280 Main St. Property Address Tracy Sullivan Owner Owner's Name information is required for every W Barnstable Ma. 02668 12/16/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Q� W TOWN OF BARNSTABLE LOCATION V Q A14 f ne S ! W&'5J r3r T t SEWAGE#-;�0 24— JR5 VILLAGE.W ,5 84 r NSTA �9 L' 5 ASSESSOR'S MAP&LOT -009-001 INSTALLER'S NAME&PHONE NO. _C SEPTIC TANK CAPACITYXls � � ` LEACHING FACILITY:(type) 9},2 (size) 2S� g 13,C X NO.OF BEDROOMS , BUILDER OR OWNER PERMIT DATE: ! -- -`2.02.1 COMPLIANCE DATE: 5—17 2--o I� 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 300 feet of leaching facility) Feet Furnished by �' Co) �� i r 13 � o 13 6 `� L/ IP Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: IlS/�11,"ll key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections �y Company Name P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S1 3742 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 Authorityicv 01/06/11 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. f Vv Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme .Owner Owner's Name information is West Barnstable MA 02668 01/05/11 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owners Name information is required for every West Barnstable MA 02668 01/05/11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 x Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s.' 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. Cityrrown 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): 3 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme _Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. Cityrrown 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ 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: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 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: 10/09/86 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.0 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.): Septic Tank(locate on site plan): Depth below grade: 1.2 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: 1500 gal Sludge depth: 3" Commonwealth of Massachusetts -UIVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme -Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. CitylTown 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 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 box was level and tight with no sign of carryover. 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.): r Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): This system has a 6'x4' precast pit surrounded by 4'of stone. There was 1'of liquid in the pit with no staining above. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. Cityrrown 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.): Commonwealth of Massachuseft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owners Name information is West Barnstable required for.every MA 02668 01/05/11 page. Cdyrrown State Zip Code Date of Ins pection D. System Information (corn.) 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 within100 feet Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately �o 51 wr 310 40 cp Go - f • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 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: 13.0 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. 01/28/1985 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test holes showed no water at 13.0 feet. Bottom of leaching is at 8.3 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 280 Main Street Property Address Kurt Oehme Owner Owner's Name information is required for every West Barnstable MA 02668 01/05/11 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file JAJ - 0 25.0� 82.34 Cn rn 9� b �3 165.00 Lot I 0�N//, qz, 0_W_ _ : C 350.00 - �D I CERTIFY THAT THE 8UILDING(S)IS LOC4TED TITLE REFERENCE:BOOK 1425 PAGE 63 AS SHOWN ANO 6b-575 CONFORM 70 Tlf ZONING BY-LAWS OF 9+zv6-rA SLE IN EFFECT NOW OR AT THE TIME OF COYSTRUC- TION AND,� Ik 7 - L IE IN A SPEC14L FL 000 NOTE THIS PLOT PLAN Nf4S NOT MADE fRIAk HAZARD ZONE AS DETERMINED BY THE FEDERAL AN INSTRIMENT SURVEY AAA JS FOR NORT- BE FARTMENT OF HOUSING AND CJRBANDEWLO M. GAGE PURPOSES Oft ,IVDr-R NO C/F_'L-'H- STANCES AREOFFSETS TO BE USED FOR ADDITIONS, FENCES,W4 LL S,ETC. A ti W II Z 6 REGISTERED LAND SURVEYO DATE Plot Plan of Land "� � .:\��•gy�p. in Bornstoble '. �;3,<<:,'`' +�.�+'�' Prepared For Rockland federal Credit Union Scale: l in.=60f t No v 1, 1996 C. W. GAR VEY CO.,INC SURVEYORS 8 ENGINEERS 36 WEST STREET WHI THAN y W SS. Is 4 / PAIPC15 6 ' \I, rT Vi of r / ; PRoVosc-D I 1 1 1 1°O' oo� A� 1 ,.Ir I f ! 1 ► 1 i r 2 26 1 p — — — SCE — .:r frr✓C-"NE'7v T n� \ - - - - •- ,1- - rRT� ly.aN ,w14Yy � 74'- �f13 - 9YP6 � IYa Jl A/ TOP OF FOUNDATION CONCRETE COVER T. CONCRETE COVERS 4"CAST �N )) .-�snr�rt i Z OR SCHEDWO 2 MAX. IS'MAX. P.V.C. PIPE 4 SCMEDULE 40 PVC.(ONLY) PITCH U4' m PIPE- MIN. LEACH PITCH LWPER.FT. 'IT PRECAST LEACWN • EL.... wV NVERT •� INVERT fErTtC TANK EL.b;07. . . DMI x' EL 1,9.E • !�, PIEGWY. . : EL.. lsQp Bo .. .. GAL. IEN4v INVERT 3/4"Tp 1V!": EL.qi-r V � � WASH90, r 1ST � � 33' '� ./foo ...• now , • 32 -�-�'-OD IA. -•� 9,, �., .�. - PROFI LE OF GROUW WER TABL� Awe of w•rTe•�e SEWAGE DISPOSAL SYSTEM sWR�P w�oF NO SCALE P- 4046 „* SOIL; LOG , ; WITNESSED BY DATE `� Z8'*-OS TIMl. /p;OQ.19!�P' ti .�t^��+`� . . BOARD OF HEALTH TEST HOLE I TEST HOLE 2I3W/}xz0 ELEV.. . ENGINEER .?Z 4p ELEV. .z3.�. . . E�• u•10 EL,st-So moll DESIGN DATA : Fives �w SR+rO ��• NUMBER OF BEDROOMS �tAv� F/NAF TOTAL. ESTIMATED FLOW GALLONS/DAY Syvo Tj• Az-IC40 BOTTOM LEACHING AREA ��'3 9 SQ.FT. PIT ,-RD.. SIDE LEACHING AREA �'S-3 9 . . SQ.FT,/PIT�3BS�•y'� SRO GARBAGE DISPOSAL (50% AREA INCREASE) Ave /fir TOTAL LEACHING AREA 307 8 Q/o.f. tz.//.oo SQ.FT �'���� /n N cLA y PERCOLATION RATE l,� .T/!A^! o^!� MIN/INCH EZ- o 00 _, 40. WATER_ ENCOUNTaftp UA44iLAW AREA PElt'PERCOLATION RATE NUMBER Of.t,EA;" RIT)i , ?/vim P r 6,�!r,�/ . . . . . �. APPROVED . . . BOARD OF HEALTH DATE . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . AGENT OR INSPECTQA _ s.•.y� ,r KELLEY tl 527 ti STEAD I PERCOLATION RATE A93,f.7149AI OM! MIN INCH WATER_ FNCOUW"" UAPHL W AREA PE1R PERCOLATION RATE Ss3S. >1Q.FT/. P. '-NUMKR Of.i.EACHM .PITS W/771 VED . . . BOARD OF HEALTH !°✓A�. E�7: ,oF S`lO^/ct' O�i A!-G• Sij�63. AGENT OR IN8PECTOR RASH OF 527 ti �' -�• Fay. �::�•;3 tttt °} '� S�NRIIPIA� Lc`G E N%� hCiSTi•vG ca.QADE p�sca G2�E � CC 2 j,f. . , . N47-4-- G-GCY.� T/c.��S �9SED on/ �9��giv S�� �"YE- L• S2d u rVl V ���� /� 71�r716 L1 , Commonwealth of Massachusetts I . Executive Office of Environmental Affairs „ t95V Department of Environmental Protection e ' } Wllllam rn Weld � 0 D�j Governor Trudy Coze Secretary,EOEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �(. PART A �- CERTIFICATION N` Property Address: 280Route 6A,West Barnstable Address of Owner: Box 176,West Barnstable Date of Inspection: 10/0 /96 (If different) Name of Inspector: Allan Taylor Company Name, Address and Telephone Numbf y 1 or As s oc i a t e s . 75 Governors way 508-362-4286 CERTIFICATION STATEMENT Barnstable ,Mass . 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: g Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspe 's Signature: Date: _c jv IC The Syste(_10n's�ftor shall submit 4s� em f this inspection report to the Appr ving Authority within thirty (30) days of completing this inspection. If the system is a share 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 Department of Environmental Protection. The original should be sent to the system owner and copieb sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: - _X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303- Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(611)W&1049 a Telephone(611)292-SSOo �et Printed on Recycled Paper l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 280 Rte . 6A,West Barnstable Owner: Robert J Wi ll.i-ams Date of Inspection: 10/07/96 B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 280 Rte 6A,WeSt Barnstable Owner: Date of Inspection: D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or pmry is 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 analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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! The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) . 3 SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 280 Rte 6A,West Barnstable Owner: Robert J Williams Date of Inspection: 10/07/.96 Check if the following have been done: _X Pumping information was requested of the owner, occupant, and Board of Health. 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 a9 part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. y The system does not receive non-sanitary or industrial waste flow _X The site was inspected for signs of breakout. _X All system components,CAIMA&Wthe Soil Absorption System, have been located on the site. including —X 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 Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -x The facility ov,,ner (and occupants, if different from ownerl were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 280 Rte . 6A,We!§t Barnstable Owner: Robert J Williams Date of Inspection: 10/07/96 FLOW CONDITIONS RESIDENTIAL: Design flow:_2gallons Number of bedrooms:_ Number of current residents:--a Garbage grinder (yes or no): n Laundry connected to system (yes or no):_yes Seasonal use (yes or no):na Water meter readings, if available: We 11 Last date of occupancy: 1 y ar + COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: r ar a"o owner System pumped as part of inspection: (yes or no)_jao If yes, volume pumped. eallons { Reason for pumping: TYPE OF SYSTEM _ y_ 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) and source of information: 1 n log/RF, Sewage odors detected when arriving at the site: (yes or no) no (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 280 Rte 6A,Wipst barnstable Owner: Robert J Wiliiams Date of Inspection: 10/07/96 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete metal _FRP—other(explain) Dimensions: 1509 Sludge depth: it Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 9 11 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, etc.) 4jzgtPm i z in v®r-Tgeeg eenditien and Was—Fdizrpc� one year acto ,home has not hPPn nf qupied Ee-' mere than ene year fluid level is Ceptri GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet.tee or baffle: Distance from bottom of curn t, bottom of outiet tee or baffie: 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, etc.) (revised 8/,5/95) 6 t - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 280 Rte . 6A,W2st barnstable Owner: Robert J Williams Date of Inspection: 10/01/96 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) s DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribui;or. 6 equal, e,,;denice of solids camover, evidence of leakage into or out of box, etc.) nigtrihiit.ion hnx was nni- Inrnt-.PH nr inc ar+t ,Ag c n c yTa„cincja(z(-tcrj and -^"^'B empty and free e€ any--grease er selids-, t4e P--bex can be assumed irt PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART C SYSTEM INFORMATION (continued) Property Address: 280 Rte. 6A,W* est Barnstable Owner: Robert J.Williams Date of Inspection: 10/07/96 SOIL ABSORPTION SYSTEM (SAS):X (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, number: one leaching chambers, number:_ leaching galleries, 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,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, 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.) (revised 8/15/95) 8 I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: r SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two perman nt references landmarks or benchma s. locate all wells within 100' W 01q, ► ► _ I I I I � I Jr�x>oc5 GACLLOP1 I I /ool' ,I i I I 1 I DEPTH TO GROUNDWATER r1 Depth to groundwater. I feet method of determination or approximation: SN4Ih/FE11>J W& i�>, s" A.I.1L7 S / IM A¢ AZS (revised 8/15/95) 9 j MAC, LY k t o- F 'gy 4. X, I <bs b. � 3,70 UPLAND ♦r�` "� .S, � Y,( , • Q Q =0 HBO MR.RSN �' eud J 'o w a AC T(.7TAl Ar- 0. w b 1pp. x: I 4"P�l Y ��p / fi "l o 04, 30- \ n 1.1 ,A ol 10 'o / t ,\ dA PL.S .''1,., P°°`V` I.Z O AC- It Ad P,IEPARED WIDER TIE DIRECTIOtd OF THE TO-\ BARi•::aTA`?lE B RD OF ASSESSORS '` AVIS_AIRt AP INC. MAS$ACMSE T rs coraMe cIlru'r ' THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA i SOR'S MAP`NO. -`i ASSES 3 L O .0 AT I O N S E W A G P E R M 11,_r__ YI IIAG E ao I N S T A LLER'S NAME i ADDRESS oe U 1 l D E R OR OWNER D DATE PERMIT ISSUED DATE COMPLIANCE ISSUED l C, TOP OF FOUNDATION CONCRETE COVERS MAX. ' •'r ` CA$T IRON 12 ,fu�AX: 0 4�. 40 hV.CAONLYI RSCNEDULE 4 SCHEbULEACM` ':p,�_C.•PIpE. PIPE- MIN. g •�• 'P)TCH I/4".PER. PITCH .I/4 PER:FTLem Rlfi` PRE e " INVERT ! y PIT o NVERT� `-INVER? DOST. T4 EL.: P* ',. $EPTIC TAi�9K Po.ay EL..t ..., e, EL.. BOX v . /4"1 INVERT INVE /� 'cp GAI,. INVERT WA! Viz, E{.., EL,/� �: � . ST( i 4 PPiOFi LE OF oROULND WATER TA w gre"r ,•'>' S6✓Arlp W«of SEWAGE DISPOSAL SYSTEM Zoeu­5 7/0 � NO SCALE `i VVIT'NESSED BY h. SOIL ,LOG �ow�N . BOARD OF HEALTH DA?E.' sl►✓ 28/yB.S`TIME ACEZC /, TEST HOLE ENGINEER 2 � !�►!�/�l'xQ; - � ,, . TEST HOLE 1" ,?3..oa ELEV. _ . ELEV., gyp: o qH 6. £L.Yx.s� DESIGN DATA . 64. SJ.90 NUMBER OF BEDROOMS p�rsr. -T-To. . . GALLONS/DAY EL. /S.9c FiN�c TOTAL ESTIMATED FLOW j " �aAYdL SA /S3. 9 . So.FT. /PIT/ BOTTOM LEACHING AREA- j' E4.4.¢o �53.9. . . Sb,FT./ PIT/ SIDE LEACHING AREA • p�� �/oRI� o FIAI� GARBAGE DISPOSAL t� /� AREA INCREASE .307 8 ^SA.FT „ i4-�" Ez.//.00 TOTAL LEACHING AREA . . . . /Q.4b•,;,, GLAy PERCOLATION RATE /�`S S.T`/A'" ,o�!� MIN/INCH EZ./6.00 . `� fb' LEACHING AREA PER PERCOLATION RATE .538. Se•III Mlo WATER ENCOUNTERED NUMBER OF LEACHING PITS �'v`� •�T BOARD OF HEALTH APPROVED'. . . . . . . "DATE . AGENT OR INSPECtiR �.. U� . f E�yrt.���+�� f ,aI Lc-Ge-ND; 20 J r .7^ I2 T 1i1//L SCE L� / — .3u ' E CBS' 1 t t � t� -`a ; .w Sa`' �,9rt "`+ r' 1 r s f ,-•+ems,: t �•�'fp � �� ' to ne Y+•t.���rt t �7" t '�J �.✓ `Y r .�Y `fir �� t�t�S ,� i' 'g MAW AM too MAN ON i z 1 bv�rt x /� / r ; s t 11 f �� f / f 711p i 7 rl��y� +t, / '�G`�`%'•%���wr ,« it ,, 1 f a ss �, J' V / t` i \• y t r 141. I f i J. + 1 v.Qca say At shy. Mi //der I f� ��'`I 1 .re, c �t1 4� •, `ay t. ..< ri ..,.ems ' �r1 WHO NZ 01 1 J 1 i I � QLy3N7L V�� ` y ;tiCal ULM f•�/ ^,'/ ASSESSOR'S MAP N0. . -`C DEL � +� � � LOCATION Ao SEWAGE PERMIT 40. VILLAGE v ALL ER'S NAME i ADDRESS e U I L D E R OR OWNER 10 I sci. ��2 ail DATE PERMIT ISSUED DATE COMPLIANCE ISSUED c-= l r s ,� r innAp 13 4 LA .a? �. , . P;XV No...... VA .All t -- THE COMMONWEALTH OF MASSACHUSETTS SUBJECT TO A?P:^"`t +- BOARD OF HEALTHBARNSTABLE �"314 ^'Y ,);1 74 !NA/.........OF......, -ST.�Y�3GL................................. Wfur Big niitt1 Workii Tonstrur#iun Permit plicatio hereby made for a Permit to Construct (cv) or Repair ( ) an Individual Sewage Disposal W at: cG/ tic/6 TLS:.....�1.........�'S!� T... .... ---------------- 1�5 a 9 Location-Address or Lot No. -74 ---------------- --.........--•--•••.....-•----••...._.... .............................................. ........ Owner Address W C ��------.-----•----------•-------•----•-------- i2 -ST7Z � 1�✓✓ T BA�Ns'Tif�GG� Installer Address d Type of Building Size Lot....'�3.-7�_c._..Sq. feet f Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 'k Other—T e of Building No. of persons............................ Showers — Cafeteria Ga Other fixtures ...---•---•----•-----------•.... . . W Design Flow_________________-...'_.........._..._.._.__gallons per person per day. Total daily flow__...........33®....._._......_.._..gallons. W Septic Tank—Liquid capacity.oSo..gallons Length__ �C...... Width.4�._��.._ Diameter................ Depth.-S_�-e�--", x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------- Diameter.......!1 Depth below inlet.... ...... Total leaching area..q�!Z-A...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results ,Performed by...�D!^! '! ..__... � ............. Date.. ... �� '�_.-..... W ,a Test Pit No. 1...4..!....minutes per inch Depth of Test Pit---•/.-�.'....... Depth to ground water........................ (i, Test Pit No. 2..:G_'..-._minutes per inch Depth of Test Pit---Zs6~.._.. Depth to ground water........................ Ix ......................................................... -- --------.----------------------------- Description of Soil------..�. ......_GOA-'.>------6-•-4-z �i v� `S,9�D--•-•-•---••f-7--"-7y---dZe�&Z_-.-----•-•------------- U ........---•................ ............................................................... 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 Wn iss by the boar boall of heal ((�� . late Application Approved BY ..`t :e� G--------- Application Disapproved for the f o l wing reasons-------------•-•-------•--------•----•--------------.....------•-----------------•---•---......------••••--._-- P ...................................... ---•-••--•-----•-••..........••....__....-------•---------------•-•----...-•----................................... .................. Date rmitNo.. .._....-••---•-------•-••......-----•---•••-•---••--- Issued_..................--- .... Dace ---------------- ��_--------------- ---- J i EDWARD E. K ELLEY REG. LAND SURVEYOR CUMMAQUID , MASS. 02637 TEL : (617 ) 362-2266 Town of Barnstable Oct. 8 , 1986 Board of Health Hyannis, Mass. Ref: Robert J. Williams , Lot #1 , 6A West Barnstable The sewage system was installed in accordance with the approved plan as far as location and elevations. It meets all requirements of Title V and the Town of Barnstable Health regulations. EDWARD rG HFL E . N0. 2is i00 eg S i Rego;, P�rofeasI., n al sANITARIP� Land reSurv:eyor THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -.............7.)a/~ ........OF....... i n/ST, 3GG F Appliration for.-Uispaual Works Tonstrudiun rrrmtt Application is hereby made_for a Permit to Construct (t_. or Repair ( ) an Individual Sewage Disposal System at: ..... ......................t '1 . M E at3 �... Location-Address or Lot No. Owner Address W G!�'r�G=--------LA!s� ---•-------------------•--------.......--- .... G�/i -52 -7' 1g//�sT �/-STi9l3�E' a ............................ Installer Address _ Type of Building Size Lot..._4 .1 .....Sq. feet Z- Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) A4 Other—T e of Building . No. of persons............................ Showers Q' Other fixtures ...................... Design Flow..................`��_.................. Ions per person per day. Total daily flow..........--..:�3c? Cafeteria 1.. W, g t� P P P Y Y gal ons. W Septic Tank—Liquid capacity_4Eq�K.gallons Length__�:K....... Width-_:f?.'G Diameter................ Depths.d.--.. x Disposal Trench—No.-_---------------- Width.................... Total.Length.................... Total.leaching area...................sq. ft. Seepage Pit No..........1.......... Diameter....... .. . Depth below inlet.... ..... Total leaching area..:3o7 a...sq, ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by....4�b^!177LZ.>-.. ....... G..-�- ... Date.. �n ..... -•••••...----- ............... Test Pit No. 1...4..Z.....minutes per inch Depth of Test Pit....! ......... Depth to ground water........................ f=, Test Pit No. 2..4........minutes per inch Depth of Test Pit..../ .... Depth to ground water.,...................... ....................................................-........................................................................................................ D Description of Soil._...._.�_":C" 4osrri 6'=4 z" F i�iG' •5�it.D 4Z'=7Z"G,QA ------------------------------------------...............................-.............................................................................. r�i 7 7'=/44.. i•-sC:Z�..l1 i^i ..............................................................."5, 'iCLIa'tj/ V0 ..___............••..... W ----------------------•----------•--•-•-•-•-----------------•-•---•----............................•--........-----•--........_...•-•-----......---•--......------._..........-•--------------..._..... U Nature of Repairs or Alterations—Answer when applicable.........................................................:::.................................. --------•................. •----•----------------------•----.........----------•----.........------...............-----•-----•----------------------....--•--••---...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of T I T LE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b6e n issue• by the board of heal Signed... .............. Application Approved BY................. ..6....... -----.. ...................------... I. .�i_. --Q�Ei Dt Application Disapproved for the f of ng reasons---------------•---------------------.........------.............------------.......--•-•--••--•-------••------ •---•......--•......:............................�..._..._.... ......................_. ................... ------••-----------•-•--------------------•-----.....-•------..............._ 1 Date Pit No..................................................------ Issued.......... - . ......................... / � Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /v A7�neSTi}J -- ..........................................OF..............................................4. ..................................... Grtifiratr of Tamplittnrr THIS IS_TO�CERTI�Y, TWtlthe Individual Sewage Disposal System constructed („o) or Repaired ( ) by................ G•.°� •---....---......•--•--------•-•------.----•---•---.------------- ------•--•-- . -------•---••-----.......--•---.....-----......-................ ._...._ cc ... .._. OUI G W t Installers at. `�. ...................�.....-----•--.............�.......--------F-=..........•...._r..�hR.�vs� .! .. .dam........ --- ..... has been installed in accordance with the provisions of T ZLE 5 of TThhe jtate Sanitary Code as described in the application for Disposal Works Construction Permit No - ...................... dated------- _ ....................... } q.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. s77rL J�SE DATE............t.pfl e?--------... Inspector............. ........................ v5 A 1vGIt,4 Ett ywV5? St.pfi2✓ts+ F COMMONWEALTH OF-.,P4 SS,,H�UfSATTS (.p�Tt1uC.�tt�l�•�� ICLTEa2 1��5/bll! �f,;'�`' G� �'t2fr�i C�'J i-►LI E'v �rj t�O RD �OF k@,kL � tJ £si�2f'a, Z f Na•d 1 S > vco�a 1�U,I�vNcyp�ci€icy? �� ,J.*- ,�,Q�1. rjova ...j I,'i '.�....... . �G v-w ( !% ....................................... Qb No......................... n ,c;�P' ,l'J�r'(',�G Fs$......a i �attl ,ark ��funfrtrrtiun Permit G&E L c,,�t�. Permission is hereby gra '�. � ---a..d.0. .... v 1 ....�� V•� !t l ......G�d1....... ... -- ....-- . 4 J ___� to Construct (I; or epair ) an Individual Sewage Disposal System atNo, .......................................•---........-•-- .. ..................... --•---••......-••-•-......................-••-•-•........ ...-----..... Street ,. as shown on the application for Disposal Works Construction Permit No. .................. Dated.._......f._�_��. ................ .....:......... .. . ... .9 . .. 166 ....**...... .... - oard!of Health DATE....... . FORM 1255 A. M. SULKIN, INC., BOSTON TOP OF FOUN DATION .,. • . CONCRETE 'COVER TE COVERS` CONCRETE + . 4 -CAST IRON 2 x. 1 M �rs+r►rrw i 2,;, •. MA2 MAx. OR SCHEDULE 4� 1 M P.V.C.;PIPE 4 SCHEDULE 40 PVC.(ONLY) a,00 - • . PIPE MIN, PITCH 1/4 PER. PITCH 1/4"PER.FT. LEACH IT PRECAST J LEACHiNG / ° N VERT cg P t,* Ze.a><.2 T • . • IT OR f L.•... . . ... INVERT _ , INNER _. #C` TANKgo DIST, . EQUIV. . , SEPTIC z.f 07 EL/9.�... ,>x . i .. S f- . ,, /30o INVERT :71. o� . •.:,„ , . . . .... GAL. I ct 0 �. W .•, 3/4 TO I V2 C •�, EL..ZQ.3Z.. i .Jl `INVERT _C ; El..f....., /8.S �� WASHED •`� EL r STONE I ,•• , . •-�- . 6.bid. PROF!LE Of GROUND WATER TABLE SW9.7p WCST of Lo I SEWAGE DISPOSAL SYSTEM lab i 3 ..5�0' .S FT f No SCALE _ s I , WITNESSED BY . ; SO1 L LOG - / 1 A tZ G;LvLe� + BOARD :OF HEALTH I.� ^► DATE Z8BS TIME. fo: ?A TEST"HOLE I TEST HOLE 2 1 .4D3. ..fi? ENGINEER / I 1 � ELEV. . is t .. . . . . . . t . .' v 1 � a3E 1 .� FL:ZJ.'�o EYtZ.So ` P p o I ,�., g� , DESIGN DATA i I wy c I j \411 � sa�►Wo' NUMBER OF BEDROOMS 9 0'TOTAL ESTIhAA7ED FLOW , . , , , . . . GALLONS/DAY _BOTTOM LEACHING :;:AREA . .,. . . .,. .SQ.FT. /PIT G.PU asA a . , . . ._. . . . SO.FT, PIT SIDE LEACHING RE /6 Al" e / 1 A- INCREASE) J v GARBAGE DISPOSAL : . . , , . ..('S0 /o ARE a 3 7 8 ST V& v 1 TOTAL LEACHING AREA . -z= aN ;.. .,s l / _ . � ~-.,- d44• 0 . . . . . . . . . 50.fT a Z4v h��n/ S Q �. I i / d1 .1 . C:LA ram,.✓--ti SS T.dq.v :D 0 Q' c1 y , PER�LATION �RATE`� . . . . . . . . MIN/INCH Cox — � ,• a!N''� r 0 58. 9 __ 3 .•1.,«�' I A N .RAT . . . ... SO.FT. _ ,. . •, � 0 ___ LEACHING AREA PER PERCOL tI0 E } WATER £'Nf)O .... ,� UNTEAED :. r , / v t Q - � � ONC- PT W� ai ( n o - 'NUMBER OF LEACHING PITS . . . . . . . . . . . _ l .� - javiz � F .vim' u r9 � r _ .. _ .. AR F HEALTH.i -APPROVED . . . WARD O HEAL H A P OV E D .. : 4VAap G ry \ , I .•..•-fir . . . . . . . . . . . .` , . . : . . . . . :, . ;: /� / I 1 IDATE , 7 � ... : : p , .AGENT OR r�SPECTOR , .. . 4 1 , Tip � O t I �pt t 1 <� l /' ,, Z Kr�tEY Rid. ,..��0� asr� • � � 9! ,r. '� - Y.r°� � � CAE'",�';a ! �€ S°ANfIARtP c— 1-- I \ + �i^ EZG'Y. TuP I ----" Z4 / \ 14 Ro - .T. 1it/iG C/�9 i 1 5 t3� 1z � hCI EAf,� GF PilVG-'/> TC�C 2a �b t�TE .S Ti�j c21/G�/O/� i /\10 TG`- G-ZCVF?Tjw.S SE7 or/ Mc4?9 w Cr 2� 7 v JC I '