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HomeMy WebLinkAbout1559 SERVICE ROAD - Health 1559 SE VICE RIDAO WEST'BARNSTABLE- AA= 174 005 001 ' `��� �:`- ,, i 4 I Commonwealth of Massachusetts 0oI Title 5 Official Inspection Form p) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1559 Service Road r�7 Property Address r ` Scott& Kara Leeman ,. Owner Owner's Name / information is required for every West Barnstable ✓ Ma 02668 8/27/2020 '0 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. Inspector Information 5/# 10r3 on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails ' I 8/27/2020 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2618 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I G i Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M e 1559 Service Road Property Address Scott& Kara Leeman Owner Owners Name information is required for every West Barnstable Ma 02668 8/27/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 1559 Service Rd West Barnstable is served by a Title V septic system consisting of a 1000 gallon septic tank, 2 distribution boxes and 2 precast leaching chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) 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): t5insp.doc-rev.N2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 1559 Service Road Property Address Scott&Kara Leeman Owner Owner's Name information is required for everyWest Barnstable Ma 02668 8/27/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is West Barnstable Ma 02668 8/27/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 iprivate 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1559 Service Road Property Address Scott&Kara Leeman Owner Owner's Name information is required for everyWest Barnstable Ma 02668 8/27/2020 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/2 day flow El ® 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. El ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1559 Service Road Property Address Scott&Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. City(rown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operato-of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2'J18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 4 II Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments g P Y �Y 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name informrequired is West Barnstable Ma 02668 8/27/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information cont. Y (cont.) 4. 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) ❑ 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): Approximate age of all components, date installed (if known)and source of information: system repaired 2001 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5feet 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.): Joints in good condition, no leakage, vented through roof. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1559 Service Road Property Address Scott&Kara Leeman Owner Owner's Name information is required for ever,/ West Barnstable Ma 02668 8/27/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. 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: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2° Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of cons7ruction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 co of current pumping contract(required). Is co attached? Yes No PY P P 9 PY ❑ ❑ 9. 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.): System has 2 distribution boxes, the original was kept inline. Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,E Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 f Commonwealth of Massachusetts r� Title 5 Official Inspection Form Of Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1559 Service Road Property Address Scott 8r Kara Leeman Owner Owner's Name information is West Barnstable Ma 02668 8/27/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 2 precast h-20 leaching chamber in driveway. Leaching chambers were found with 6"standing water and no stain lines higher. Steel ring and cover to grade. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I Commonwealth of Massachusetts p Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required fonevery West Barnstable Ma 02668 8/27/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 �— L #___J J� P Aj 2 �. '6 i37 lq �3 276 � zz , c ZS 6 i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments * / 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. 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 plan reviewed` Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 1559 Service Road Property Address Scott& Kara Leeman Owner Owner's Name information is required for every West Barnstable Ma 02668 8/27/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ENVIR0 TE CH LA WINTORIGS, INC. AM CURT, NO.: 11•-111[ 003 3.1mi Sebastion Drive UuiJ 12 Sandwich,4111 02S63 (508)888.6460 1-80/1-.3,39-6460 FAX(503)888-6446 Cliett!A'Wite: kivaneed JNater S}srern'c Lucridoit: Kara Leeman Addre,ts: 778 Main St. 1559 Service Rd Osterville,MA W Barnstable,MA 02655 L«b Nrtrt►ber: DW-202845 t:'0/lecled By: Patrick Irvine Dole Received: 08/14/20 Sullyde Tphe; Kitchen Faucet Nell Specs: Treated Sample L(1CRlfD/J.S ITCc .. U of ale Collecle[l Tl►►e C o ected 11 .':141:00 14 :08114/20 .Inulpsis Requested Units Reemninended Limils A►rtrflsis HesrrlJ Alelbnd Dale.1►raljgerl Analyzed 1(t, pH pH units 6.5-8.5 7.34 SM 4500-H-8 08/14/2020 SO Specific Conductances umhoslcm 500 194 EPA 120.1 08/14/2020 SD Nitrale-N mg/L 10.0 0.74 EPA 300.0 08/1412020 LL _ Sodium mg/L 20.0 8.2 EPA 200.7 08/21/2020 KB Total iron mg/L 0.3 <0.01 EPA 200.7 08121/2020 KB Manganese mg/L 0.05 0.012 EPA 200.7 08121/2020 KB Calcium mg/L N/A 27 EPA 200.7 08121/2020 K8 IMagnesiumn mg/L NIA 2.9 EPA 200.7 08/21/2020 KB Total Hardnessa mg/L 50-200 79 EPA 200.7 08/24/2020 KB Chloride mg►L 250 13 EPA 300.0 08/1412020 LL Colors APC units 15 <5 SM 2120B 08/142020 SD Odorn TON 3.0 ND SM 21508 08114/2020 SD TDS mg1L 500 122 SM2540C 08/142020 SD Comments: All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otheWse noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. l�G' t-� '--� Ilrrle 8/25/2020 Kururlrl J,Saarl / Laboratorr Uirecl RRL=-.Relon•Relwrrahle Limits %!e,hlrrrhed Page 1 of 1 rCer►ffiealioi►Js not available frrr- irairr samples.. I` F Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a / S9 S61✓vice e-2� Property Address + // Cw ner Cw ner's Name information is C>�eS iJa/✓�S7 c / /7 00� 6 / �� �� required for every page. City/Town State Zip Code Date of 4fispecti6n 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. Mpotorms ou forms t fo A. General Information Men filling out on the compute-, use only the tat 1. Inspector: key to move your cursor-do not use the return Name of Inspector Company Name Company Address Z�"_ City[Tow n L— G,s Stale Zip Code Telephone N er License Number ,,LP L, B. C rtification 4 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 Of 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 16.340 of o Title 5 ( �1'@0 R 1.6.000). The system: r101 ;asses ❑ Conditionally Passes ❑ Fails O , Cj ❑ Needs Further Evaluation by the Local Approving Authority P, /-7 Inspect Vs 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 sett 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. V v /) 10 t5ins 3113 Title 50fficial Inspection For 0 slace Sewage Disposal System•Page Iof17 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments � 59 ser Property Address ON ner ON ner's Name information is /Sb�� required for every h/� [�G�✓�Sf� page. City/Town State Zip Code Date of nspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E l 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 Healt h. *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): 15r s-3113 Title 5 official Ins pecbon F orm SUIDG rface Sewage Disposal Syslem-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /SS9 Sery/c e 11�oj Property Address ,a (N ON ner Cw ner's Name / � /information is W aaS 'Ll' /��required for every page, City/Town State Zip Code Date of Inspectl6n 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 16.303(1)(b)that the system is not functioning In a mannerwhich 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 t5ns•Y13 Tlse 5officiel Iris peC6mfam Subeurfece Sewage Disposal System-Page 3017 Commonwealth of Massachusetts x W Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ��f/✓1 1 vt ON ner Ory ner's Name/ information is required for every page. Crtyfrown State Zip Code Date ot Inspe tlon B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning Ina 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 ❑ E�,-' Static liquid level in the distribution box above outlet invert due to an overloaded / or clogged SAS or cesspool ❑ ,L��,/' Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow «ns-Y13 Tide 5 Official Ins pec don F orm Subsurface Sewage Disposal System-Page 4of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /..S 9 Property Address /� o(/t4rh ✓l O,v ner ON ner's Name // /information is r ' required for every page. City/Town State Zip Code Date of Inspecton 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; ❑ L� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ �f Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ L7 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ET Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ud 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 fLb I have determined that one or more of the above failure criteria exist as described in 310 CM 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. Ens•X13 Title501Bcial Iris pectlon Form Subsurface Sewage Disposal System-Pape 5of 17 �L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Y o to Assessments ry Property Address Cw ner ON ner's Name information is //�� required for every _ �I�ST Gi✓rr a A% 1;71-zpage. City wn S tate Zip Code Date of I pe 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? ❑ Q--' 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) �Q. 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? i �❑ 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: r, Number of bedrooms (design): S Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): t5 ns•3/13 Tine5officlel InspectlonForm Subsurface SewageDlsposel System Page 60f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° /SS9 Se✓vic e /2"J Property Address Cw ner ON ner's Name information Is required for every page. 5 fTown State Zip Code Date of Inspe n D. System Information Description: xJC) I Number of current residents: / Does residence have a garbage grinder? El Yes 8 No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes EJ'No Seasonaluse? ❑ Yes B No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes L_7 No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: �13 Title S 0f trial Iris pec 8m Form Subsuiece Sewage Disposal System-Page 7 of 17 �L\' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments JrP r `C' Property Address Ow ner Ow ner's Name information is ��5� (SG�✓ts ��i� O�6 �� required for every page. Wfown 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 Lam' No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of stem: 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 (descti be): 15ins-3113 Title 5 Official Inspection F orm Subsurface Sewage Disposal System-Pape a of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G Q Property Address Cw ner ow ner's Name information is required forevery QS ��r✓lf --!1 �66g l page. City/town State Zip Code Date of I pection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Dept h bel ow g ra de: 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: / feet Materian truction: 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: S Sludge depth: 151ns-3!13 Title 5 official Inspection Form Subsurface Sewage olsposd System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ON ner Owner's Name information is �, /PS /lG/4 f i/e �� required for every W J page. City/Town State Zip Code Date of I spectio D. System Information (cont.) Septic Tank (cont.) S Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? o le- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Cil N'1 yl {/70 rZ 2L 44 bl J—I✓L2 l4;^41 '-4&4 117 o Cori G��ro✓I , 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 t5m-3/13 Tide5C)Mclel InspecticnForm SuosurtaceSewegeDispossl System,Page 10of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Iss? Property Address �'1 Cw ner Ow ner's Name _/ / ,y a Information is �/es /�5 � � ��/� Oo��6� � required for every page. Crtyrrown State Zip Code Date or Inspe tlon 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 t5ns-313 TWOSOfftciel Iris pec don Form Subsurfwe$"eDisposel System-page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /3-S9 Property Address ref rVJ/`'1 Cw ner Ow ner's Name information is required for every yyVV 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 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.): &/0 Pump Chamber (locate on site plan): Pumps in wo6,ing 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: tSns•3/13 TWOSOfflciel Impec Von Form Subeurtece Sewage Disposel System-Page 12of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner Ory ner's Name / information is required for every /ll�s� ✓�f �b page. City/rown State Zip Code Date oVInspectVirt D. System Information (cont.) Type: (��) CQ 0 Cry��o C�GV'/41- 11/ ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Aalo'll' o 6; Cesspools (-;esspool 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 t5ns-W3 Tile 5Official Inspection Form SubsufweSewageDisposal System-Page 13of 17 L Commonwealth of Massachusetts ,gal 45T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Ow ner's Name information is required for every �S 7� (��✓✓�17�b dv���o / h�"- page. Gtyrrown State Zip Code Date o 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 (ncte condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ns•3113 Title50fBCial ftpection Form:Subsurface SewageDleposd System Page/4 rs ea of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address (/L✓Vl I✓� Cw ner Cw ner's Name / information Is Q� 6� 9 �� �� required for every page. cityrrown State Zip Code Date f Inspection D. System Information (cont.) Sketch Of Sgwage Disposal System: Pro\Ade a view of the sewage disposal system, including ties to at least W permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where✓ blic water supply enters the building. Check one of the boxes below: rnd-sketch in the area below awing attached separately 1 tgns,3;13 TO50fflCiallnspecGonForm Subsuiace Sewage 01sposel System-Page 150f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner Oyu ner's Name information i required for every (il. l G/✓I,f' b � D�((� � f� �� page. cityfrown State Zlp— Code Date Inspec Ion D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: [late ❑ Observed site(abutting property/observation hole within 150 feet of SAS) �Che7�,7 'thl Board of Health -explain; - -- (ems f ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: 410 Before filing this Inspection Report, please see Report Completeness Checklist on next page. tans•N13 Tiue5Offlcial inspecganForm Subsulace Sewage Disposd System Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cw ner ON ner's Name information is ��s� c✓✓�s���� /`�,� Q���y � �9 ��required for every —.L page. 5 flown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked E?"ll-spection Summary D(System Failure Criteria Applicable to All Systems) completed L`1 Sy-stem Information- Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tins•Y13 TiWC"cial Ins pec bon Form Subsulace Sewage 01sposal system-Page 17of 17 ...•c.iao-o+ 2-` .�,.i-7ocis+..4.:,.-�ai;.;.ii_.... .. N . .7_ TOWIN OF BAD NSTABLF LOCATION SEWAGE V LLAGEy # U4'1-2 ASSESSOR'S IvL-�P & LOT�'?!L LVSTALLER'S NA.�If PHONE NO. j SEPTIC TAINK CAPACITY LEACEU G FACILITY: (type) NO. OF BEDROOMS BUILDER PERMiTDATE- Lj_ ( -v r COMPLL-�NCE DATE: S-- 2 - Z•h; Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f Private Water Supply Well and Leachin Facility Feet g ry (If anv wells exist on site or within.200 feet of leaching facility) Edge of Wedand and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) J Furnished by �C7" Feet —, y b i �__ i� ,q TOWN OF BARNSTABLE li L-R-A.'IION _ SEWAGE # JO01 21 Z V-ILLAGE Ufa �3�tr`r5 '� ASSESSOR'S MAP & LOT)71,),OOs��% INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /,,Aee ea¢11 - Zo O -6-0-0c LEACHING FACILITY: (type) fed 6 `,-v,4 6-&,wij C�(size)/d jc 3v:) NO.OF BEDROOMS 3 BUILDER O OWNER kriOLZE PERMITDATE: -v I COMPLIANCE DATE: S- T - zc9vl 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) _ 130 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) ` Feet Furnished byC�� ;,, C �, �.. � � � ` �,. �. � ✓ . . '� O �' �� -Ll a� �s .0�.� � '` 1 i `` �y� - � � .` .'. � _ �t�:, No. (/` Fee C / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Rppltratton for Diopogal *pztem Con5trurtton Verna Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System LiTIndividual Components Location Address or Lot No. �^� ��� Ow�-n-�e—r's ame,Address and Tel.No. Assessor's Map/Parcel w.✓ V phi AVIAI 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(_0 Other Type of Building vzo khn�No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ile gallons per day. Calculated daily flow 73Q gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank lope m Type of S.A.S. ?--L5PO e Description of Soil a Nature of Repairs or Alterations(Answer when applicable) ) 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 been issued theB �S�_ > Signed Date V T 40 Application Approved by Date 0 Application Disapproved for the following reasons Permit No. -Z</O ` Z Date Issued g ' No. � `.�� -- ,• �° Fee S� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: + - Yes - � PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppfication for Mi.5pozar *pgtem Construction Permit Application for a Permit to Construct( )Repair( /Upgrade( )Abandon( ) O Complete System Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer' 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(�0 ,Other Type of Building Ae 211*ehUeNo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 33.0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank lief 9Q' Type of S.A.S. 7- Description of Soil Nature of Repairs or Alterations(Answer when applicable) 11-),7``le Z o"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 has been issued b this Bo d of ealth. I / Signed Date 9t 7/e/ Application Approved by V Date �f / 'Application Disapproved for the following reasons Permit No. -ZGO l Z Date Issued q—°! —U ,t ,•< a THE COMMONWEALTH OF MASSACHUSETTS 1 '7ZI SF '/ BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT Y,that the On-site Se age Disposal System Constructed( )Repaired ( ✓)Upgraded( ) Abandoned( )by !?f- X0 3 at /�i�.S~�l eo r!//�'� /� ul, 1J/N,i;.�4°� has been constructed in accordance with the.provisions of Title 5 and the for Disposal System Construction Permit No. -Lw�' t "Ldated 14_ 11—0 t Installe- I Designer The issuance of this permit hal)not be construed as a guarantee that the system will functio designee . Date V Z./ Inspector .?` I ---------------------------------------- No. � � � /Fee THE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi.5pozar *p!5tem Con.5truction Permit Permission is hereby granted to Construct( )Repair( pgrade( )Abandon( ) System located at f�s:� :7 ff bllC'e Y� UW/ 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 Date: �/ Gj _ Approved by '`� '//4A, r�/ / TOWN O1~BARNSTABLE ! LOCATION . SEWAGE # 2,5df. 2 VILLAGE ASSESSOR'S MAP & LOT I /- -dOs �7a/ INSTALLER'S NAME&PHONE NO.__ Dorms SEPTIC TANK CAPACITY -- /,GCD Cy�l - O - LEACHING FACILITY: (type)2!E G l Z,-r, (size)ld X NO.OF BEDROOMS � BUILDER OAR OWNER ' PERMITDATE. /-1 ��• -� ��. . � -COMPLIANCE = 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) �S .. Feet Edge of Wedand and Leaching Facility.(If any wetlands exist r f within300`feet of leachin facility) Furnished by. CT Feet' .'. f. ¢y'4 Cityt.@`;:r t .F..t�-r '. s; tr` �(it € � 10 ig } t tit�� t +i j �{ r as ,y� L /53��. � ,y' P D !De/'`oyrtDyE TIM N Ste/ 6 0 c-� DESIGN/: .PPLICAi-1ON 4i rr Or B ZDROOMS=,fired desimtd gpd: SiDIBWALL: Ien �n /0 X wide.*+ Z X no. sides Z =— Z�;q Ipn h _ X width 2 X.no. codes Z = 12,0 sq. � Sidevrall area v,idth L Bo Cora area 30© "total 2: M Zsq-Z- �l e 7 q = 3 ®� desipad (application rne) PIlons/day N � 0 0 E STANDARD LEGEND ` \ NOTE:not all.symbols will appear on a map GOLF COURSE FAIRWAY \ z EDGE OF DECIDUOUS TREES EDGE OF BRUSH ORCHARD OR NURSERY 9 V--V -V EDGE OF CONIFEROUS TREES ---- MARSH AREA EDGE OF WATER DIRT ROAD DRIVEWAY PAVED ROAD - ;; DRAINAGE DITCH (z \ PATH/TRAIL i PARCEL LINE MAP 174 21Ito-<- MAP# } rl } / -<— PARCELNUMBHOUSE NUMBER #186 ' ---� 0 e a #1541 � 2 FOOT CONTOUR LINE �-74 10 FOOT CONTOUR LINE if # 5 2 MAP 174 Elevation based on NGVD29 .-` 5-1 ' 4.9 SPOT ELEVATION #1559 MAP 174 <x o STONE WALL 5-2 - 4 #1567 6 MAP 11 17 X— —X FENCE #1585 RETAINING WALL }---;—I-i RAIL ROAD TRACK i STONE JETTY i ( j SWIMMING POOL PORCH/DECK / 0 BUILDING/STRUCTURE DOCK/PIER — — HYDRANT ' I / t e VALVE O MANHOLE / o POST p ' FLAG POLE T O W N O F B A R N S T A B L E G E O G R A P H 1 C 1 N F O R M A T 1 O N S Y S T E M S U N I T a SIGN ® STORM DRAIN Iv PRINTED S[AIE:IN FEET *NOTE: Plonimetria,topography,and **NOTE:The panel lines are only graphic representations DATA SOURCES: Planimetrics(man-made features)were interpreted from 1995 aerial photographs by The James = m vegetation were mapped to meet National of property boundaries.They are not true locations,and W.Sewall Company. Topography and vegetation were interpreted from 1989 aerial photographs by GEOD 0 UTILITY POLE n TOWER Ma Accuracy Standards at a stole of do not represent actual relationships to physical objects Corporation. Plonimetrics,topography,and ve etation were mopped to meet Notional Ma Accuioc Standards Q£ 50 1f)0 P V P P P Vs I P 9 PP P V O LIGHT POLE O ELECTRIC BOX s I INCH=100 FEET* 1"=100'. on the mop. at a scale of I"=100'. Parcel lines were digitized from 2000 Town of Barnstable Assessor's tax maps- NOTICE: This VoimJs To Be'Used For the Repair Of Failed Septic Systems.Only. - CERTMCATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS_CONSTRUCTION PERMIT(VV=0UT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated l b D concerning the property located.at all of the followin, criteria:. /T7n- 53mem is c ezze Pit. Q er onn__.��c0 3 rests,aCal c1w ..tn_oniv. in_.e are no commerl:al or business .uses ssecated with the dwe+t—ina. �! Tne s•cil is classified as CLASS I and the pemoiatian mte is iess ;=or eauui :o. mmuics per inc. � here arm no we•,iands within 100 ee:of the;,roo_used SeDuc s;stem i nere are no a-,:. e we2s witrin.1:0 .of:he prow ed —_—sr sync ,�,1em. Y fief is no incMse in tow and/or.shame in--ise x000sed i here are no Yaranc2s,=usL.d or need✓± +� The bottom-of the proposed leaching facility will not be located less ,j=five rmt above ae marmum adjttsted,groundwater table elevaton. (Adjust the--ound-Aster.tabie.tsing the I imptor method when applicable]. if.the S.A.S.will be located with_50 feet of a.-ty veQP ated we lands. the bottom rot p . on of the esed leaching facility will not be Iocated less than iourtern(14) feet above the ma.-dmum adhmed gound,;ater table elevation, Please complete the following: A) Top of Ground Surface EIevation(using GIS information) 37 G:ViT.IIevation l(� =th;MAX iiign G.M. Adjus�ment. �� = 7 Z D.l*F—tRENCE BETWEEN A and B SIGNr"D . _ DATE: l P PP em� yst on back]. health folder.eat jai John Grad D.E.P. Title V Septic Inspector 564-6813 SUBSURFACE SEWAGE DISP09AL SYSTEM INSPECTION FORK _ _ Address of.1property-Idi"I Service Rp B�rn51ab1c Owner's .name :` hePtci J Date -Of' Inspection IP PART 1 ""t I99 L7S DD CHECKLIST TM OF , . Check if the following have been done: Pumpi-ng 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 as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on exist: ng information or approximated by non-intrusive methods. - The facility owner (and occupants,p if different from owner) were provided with information on the proper maintenance of SSDS. BVBSORFCE "BEKAGE DISPOSAL SYSTEM INSPECTION N< :. r. PART B . FORM SYSTEM TNFO RMATION /i FLOW- CONDITIONS If residential - -~ 3 number of bedrooms - - number of current residents_ garbage grinder, yes :or no laundry connected to system, . es or no seasonal use, yes or no Y -- - - - - - If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: — System pumped as part of inspection yes, volume pumped yes or no Reason for pumping: • C TYPe of 'system _L_ 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) p ction Other (explain) Approximate age of all components. Date installed information: if known. Source of w� NO Sewage odors detected when arriving at the si te, yes or no s .. .s. . marNO �A s 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM ,f� a PART :B r SYSTEM IN70RKATION Continued : ..SEPTIC TANK.`. - - (locate, on _site plan) -- - - depth below grade: - material of construction: ✓ concrete metal FRP other(explain) dimensions: L � Lip 14S 7` . sludge- depth - ` 3`' distance from top of sludge to-bottom of outlet tee or baffle scum thickness `.distance from top of scum to top of outlet- tee or baffle W . d-i-stance from bottom of scum to bottom of -outlet tee or baffle Commen .s (recommendation for pumping, condition of inlet and outlet tees or baffles, depth .of liquid level in.-relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) SyS��►, 5�.1� 6� J4_)""A e-A eery '1 y1&,r5 DISTRIBUTION BOX: �IYS (locate on site plan) level ,,,,L11*1 - &44cm depth of liquid level above outlet invert Comments: (note if level and distribution is equal , evidence of solids carryover, evidence of leakage into -or out of box, recommendation for repairs, etc. ) PUMP CHAMBER _ (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances,, recommendations for maintenance or repairs,etc. ) r� " SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION FORM +KART B SYSTEM' INFORMATION -Continued SOIL ABSORPTION SYSTEM'-(S'AS) - (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive .methods) - If not determined to be present, explain: - Type - leaching pits- and number leaching chambers and number - _leaching galleries and number leaching trenches, number, length - leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition . of ve etation, recommendations for maintenance or repairs,etc. ) SYS�@rt �n W l b;� L A42 t`n CESSPOOLS (locate on site ) lan : P number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of constructionf�A dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) / -a., � f't � .gy;,�}"-• {�'+;.i. d r_ 4"4 4ty(T.r h yu 1 tf ••.�- t t _ _ SIIBB IIRF ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK PART 8 SYSTEM INFORMATION continued SKETCH -OF SEWAGE DISPOSAL SYSTEM; - include ties- to at least two permanent references landmarks or benchmarks locate all wells within 100' AA c � a I AZ AC vp 43' DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: ; s. , SUBSURFACE: SEWAGE DISPOSAL SYSTEM NS Z PEC TION_ FORM - PART C FAILURE CRITERIA Indicate yes, no, =or: not"determined (Y, -N, or ND) . - Describe basis of determination in 611 instances. ._If "not determined", a:'plain why not) Backup--of Sewage into -facility? Discharge or ponding of effluent to the surface of the ground or surface waters? --- -- - - - _ . Static liquid .level. in .the distribution box above outlet invert? Liquid depth in cesspool <6"- below invert or available volume< 1/2 da - flow? Y Required 4 times pumping or more in the last year. number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? _4f within 50 feet of a surface water? _ within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? JV within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? ,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 analy: for coliform bacteria, volatile organic compounds, ammonia nitrogen f and nitrate nitrogen. 13 c BUBStiRFACE SENAbE .DZSPOSAL. SYSTEM INSPECTION FORM PART D - _ CERTIFICATION _ Name of Inspector - P _ . Company Name JOHN GRACO Ttie I Inspector Company- Address_ P.O. Box 2119 - Teaticket, MA 02536 Certification Statement - - I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of- the time of. inspection. The inspection was . performed and - any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. one: !711 have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR +15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspe=tor' s Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority S_ 1 � - b' 7 --- --=--- ---- TOWN OF BOARD OF HEALTH ' SUBSURFACE SEWAGE D`iSF'OSA1; °SYSTEM INSPECTION FORM - PART D - CERTIFICATION �. -TYPE OR PRINT CLEARLY- - - _PROPERTY ,INSPECTED STREET ADDRESS _ ! ? `� �c�►� - AS MAP , BLOCK AND PARCEL OWNER-' s NAME PART D - CERTIFICATION NAME. OF INSPECTOR . - JOHN GRACI COMPANY NAME nspector - COMPANY ADDRESS St 536 Town or city state LIP reet P.O: Box 2119- COMPANY TELEPHONE ( 5Z*) Sjq CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : ystem PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environmen t as define d in 310 CMR 15 . 303 , Any fa ure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED$ The inspection which I have conducted has found that the system fails to nr ot.ect the public health and the environment in accordance with Title 3t0 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature r �G Date 07�' One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or `operator shall upgrade the system with-In one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc r . AsBuilt Page 1 of 1 �r ASSESS& 'S MAP NO.I')4-00-�;-I PARCEL L & L0CAT ION r SEWACE PERMIT NO. VILLAGE Se► p"',Ce. INSTA LLEA'S NAME A ADDRESS 6-7 s UILDE R OR OWNER DATE PERMIT ISSUED �z DATE COMPLIANCE ISSUED c— 73 4Z' h 5 � c� �ss •� � http://issgl2/intranet/propdata/prebuilt.aspx?mappar=174005001&seq=1 2/13/2014 -ao l •� ASSESSORS MAP NO.) )/-/oa5—PARCEL LOCATION SEWAGE PERMIT NO. 5---- — k.0 V I L L A G E .5-c r-1 -C e. INST A LLER'S NAME i ADDRESS 5 G U I L D E R OR OWNER a DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i �� �Z' � �ti r � ® �, v � �� �� e � /� h �� � � .�� S �4 t:i �-c� ass � � NO .....`ids _ Fss _, �-� THE COMMONWEALTH OF MASSACHUSETTS �- �0 ` ✓ BOARD OF HEALTH ................ 48LE. ,1jiVRratiuu for lliuVuual W urku Tuuutrur#iuu Prruti# Application is,-hereby made for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal System at: ......-...L>OT....Jr..... CGEJS 0:4! ....---•--...._... ..L.............................•-----....---.......----••------••---......_..................... Location-Add e s or Lot No .. v/�1E� 0, ��D /��- lllt�v_ . .. v � ss Owner A re,, a t Insaller " 1.r (� Address U Type of Building ` Size Lot_(Zj_44gf__Sq. feet 42 �-, Dwelling—No. of Bedrooms.______.________.............__________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building a g --------------•----•-------- Now of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------•-------- W Design Flow.............%:!Jam..______-_____.______.._gallons per person per day. Total daily flow.................55.� .._._.___.__...gallons. WSeptic Tank—Liquid capacity�=..gallons Length__8.� ._ Width4_ /a .. Diameter________________ Depth_____:�_�.... x Disposal Trench—No_____________________ Width J..._..��__._....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......___/......... Diameter,/Z-0__-_._. Depth below inlet_.,-3......7.... Total leaching area__44S.._.sq. ft. Z Other Distribution box ( V) Dosing t``��nk ( Percolation Test Results Performed by..___.. d...... PE_. v v ©�/�8(0 � i1.................... Date--••---..._..-•- -------- Test Pit No. 1..."'_1......minutes per inch Depth of Test Pit__i44__;i_____ Depth to ground water......... ............ Cc. Test Pit No. 2__{.Z i___._minutes per inch Depth of Test Pit.../.QQ._....... Depth to ground water.....___.._.—_.._... --------------- _ O Description of Soil....... .. �--•--T !� '� SC/ �lL� ��__.."� 4 /!fU11Cf� QM E -•-------•--- w 1G7..... �STo.� #2 D"-/ " ":..�4y"- rEo.-- stp .... V Nature of Repairs or Alterations—Answer when applicable___:y�... _•____ �/w`c �.......----- Agreement: C& I -Aq c Tc: t=> - l-.� N PNT � S�Srr�,�.................... Aa fil� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance wit)o the provisions of TITLE. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in T"V op ati nt' a Certificate of Compliance has bee is ued ythe boardf health. d� Signed ............. Application Approved B .. Application Disapproved for the following reasons___________________________________________________________________________________ ----.._..Date.............. ...........................•-----..._....---.._...-----...--•-----------------------------...__._....-------._._._......-------------•--•---•------•••••-----....----•--------•-------••----•--•--_..... Date PermitNo______ _ ___ ....... `r ........ tIssued-....................................................... Date No t Fss.'= " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... OWN................OF.....U� ��tIJ TA.�.6�.LEA.-•--...... -�ppliratiott for Disposal Works Tonstrttr#inn Permit Application is hereby made for a Permit to Construct ( V/ or Repair ( ) an Individual Sewage Disposal System at: ...........................o 5....�rcE55 T�� .................. ..................••...-••-•-•----------•-• .........------••--••---•......•--._....•- - L,,-ion-Ad e s - ' / E� `S p1b�6� or Lot No. .......... --(�................./ ........./............. ..... ......._................................•. •--•--....---...._......•••--_........•....... Owner Address a ---•-••---- a c-- ---- .�..�--- .. Installer Address U Type of Building ] Size Lot..6I?A4__91`_.t..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W` Design Flow............�5�`-......................gallons per person per day. Total daily flow_................�0...............gallons. WSeptic Tank—Liquid capacity�� ?__gallons Length.. �' .. Width�.fU Diameter................ Depth�__7.` x Disposal Trench—No...............:..... Width�......�........... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------/......... Diameter/2t�.2.'. _...__. Depth below inlet ._.:. ...._. Total leaching area..2 .�.....sq. ft. Z Other Distribution box ( i/) Dosing tt nk ( '-' Percolation Test Results Performed by 2&4_ __�r1 P I--- ..................................... Date......;1...3.. . 'rest Pit No. 1......... ._...minutes per inch Depth of Test Pit../`_ir 4 Depth to ground water........................ f=, Test Pit No. 2....... .........ntinutes per tech Depth of Test Pit... ........ Depth to ground water..........._____...._.._._._. a ..••• i ........................... Descri tion of Soil.... ./...(� Z�,; �U� ��/ U/L y � 14 ' r/A/c .��'!vp .SCE�'C.... x \� _ #.... D � W �.... ......................................... ...............> M ....................................................................................................... . ... ... ......................... ............ ..._...._.. ...__ ....._•___.._.. trj I, ature pairs or Iterations—Answer when applicable_._ ...: � 1N� 61> 4�. N1 t��a �V W Q 1 ry�,P-,-, _9-P20n .,ems ------- ,•v„�� C���t Zri ��Z71 N SASwr�C -- Agreement: CtT aiuS A r7"c br- j r:'�G Hi z The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with-r t'`OL, the provisions of TITLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in open9t�nti a Certificate of Compliance has been issued by the board of health. Signed............................... Application Approved By.................... ..�.G_"1__. / � •.............••-•••..........- Date •.................••-------......................................-•--- ..........._ Application Disapproved for the following reasons:..................... - ................ ...............•-•----.....------•-•------•-----------•-------•------•----•------•--•--.•••...••----••••••••-•--•--••••.....•-••••....•-•••-••.......-••••••-•••--•••---•-•••..:.•-•--- +. Date Permit No... J .. .....-�...••---- Issued........................................................ Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............D. ..............OF.......... _ (9rdifiratr of Tompliattrr THIS,I O CERTIFY i e vide Sewage Disposal Sys e c n tructec ( or Repaired by.............:.�.... .••...................................... ------..�.... •--•--......--••.. . ......................................... In taller: at....... �;,,(�� _: c. --�'�a_._... --------------------------------------••--••-------------------•-----.-.----------------•---------- has been installed in accordance with the provisions of T 5 6 odeas—described State Sanitary C in the application for Disposal Works Construction Permit No..Z = - -.._..'.7' dated..... fl.. ................. THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL CTI N SATISFACTORY. DATE..................... ....... ... ...................------......... Inspector........L�A................................................................... 1 THE COMMONWEALTH OF MASSACHUSETTS (- 5 ..............BOARJ HEALTH..........I-0.. t/VN ..OF........... ... � � Gcr, �N W,��7acTI iopontt C n`rko vn,*udiott Permit Permission is hereby granted................. `" - ..._ ....._.__......_..... �.(. Y `�--}�1 to Construct ( ) or Repair ( an Individual Sewage Disposal System at No...-•••••••••........t---.c,f ----...----- - Street 4 ng r as shown on the application for Disposal Works Construction Permit No................. ated..... ...........................L....G'...... - ........-•---.--............._ 910 DATE................ 3_ Board of Health FORM 1258 HOBBS & WARREN. INC.. PUBLISHERS +' 47 40. «-- 1 • \ RIff r."•^` "`" �� x' R .f w,...,.r 100 i 00, if LO • A •n„ a� i Y w� ` ..- •.,,., •..,,,. „r y:• � tom, g I .. ♦ , 4: S{,1 9i ws�ns `X., `"'....,.°^ w•'^"` i. 3 d 0.YY X 6.� . • tea. � A. ,�;^'/°.> Jir x i;` � f �4, '1. 10 P6Aof I r. A PJA , rf.k. ..�.,..•,._ `^ ,.` '''y� ., ' y:� .. ;+ •s..,��«. ,t �y .3 .+'' �'' 4a! G".w a ��` p . .:04 ! 4 CE 3 p 4P. r 0 A f _ ..:.. ., .:" ., ::::, ,...: ..,:<.. ::. ,. .s✓a-%ui' t+[^svv,. ". .{.a _. '{3 ... ..... .. ...s&'... #ifs` M�`Y43. -. .3;"t ... • a y9{, :sue — N INLET KNOCKOUT i 1y4 10" 24 #j t o .r t: 4 A 1 + } t 1 t rYf f.:' Y 1ir,�� { } t s:+'L- /1 - __ {' • j ` r T f a r ' i F , - ;1ot r ' ;j 0i t 10 0 , .g � . ( t row : uwow A } 0 �" �, 19 t> Lit t +C/,' ,�/"'1 V 1r��S PR4 *4CIZE 4104 FM Q - CT - _ r � ir �} ! C) �/ _ 3 -- 4 it 0 0 G 00 C % C) 0 0 t, � f, r, ..� t f ' TOP A `d!a 7'0P Quv j suesoic ( g'' , cf-AS rIRO l O� SC 3- ,PEMG' ' AL� fJft/ l� �BLE TE '/, .souE , rov�" ,C:),41 L /';'car; /E,D lL"�.`-%`, /' njo IT20 .v0 ?jr6 N Usti G'Th'ERI1/`5E N6 Ate:' y,�.aQ.clsTilBG£' A R49 -fL ", i' JE SLR : / .3/ 86 6, ' _ h/ E /T A.—L ��:' I BA 01 BER te V AMOZ6 Yam , Ow , i A Nrc MA Y 3E. PP1- A--A E 115 T /5 T AIN � LA1rf � � _ - //- Lor ;t�- ACCZAA ROAD /,k/5T,,4 Z �'ELF OA1 , �� 5 Y'S 7"E�f. ��, J 4 77 E3� 40X 3 J w r^' < n+ ;