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Home My WebLink About0100 SHOOTFLYING HILL RD - Health .4 t. 100 5hootflying Hill Road West Barnstable / A= 214-065 :r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name I,� p information is WO �iVVIS ✓Ilr MA 02632 9/11/2014 required for every fa page. City/Town Z14 Gas 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: key to move your cursor-do not Linda J. Pinto use the return Name of Inspector key. Oceanside Septic, Inc. � Company Name P.O. Box 201 Company Address Brewster MA 02631 Cityrrown State Zip Code 508-896-1513 4432 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C) 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. t51ns-3113 Title 5 Of clal Ins :Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 ® icial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "( 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is required for every Centerville MA 02632 9/11/2014 City/Town page. 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-3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is Centerville MA 02632 9/11/2014 required for every 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 ❑ Y q P P 9 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,3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner owner's Flame information is required for every Centerville MA 02632 9/11/2014 page. Cityfrown 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 YZ day flow t5ins•3/13 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is required for every Centerville MA 02632 9/11/2014 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. t5ins•3113 Titre 5 official Inspection Form:Subsurface Sewage Dlsposel System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is Centerville MA 02632 9/11/2014 required far every page. City/town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of El 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. ® El approximation in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 548 t5ins•3113 Title 5 Official Inspedfon Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is required for every Centerville MA 02632 9/11/2014 page. Citylrown State Zip Code Date of Inspection D. System Information Description: 1000 Gallon Septic Tank, D-box, and one 6'x 8' Leach pit Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail 2013:44,000 Gallons(121 gpd) 2014(1/2): 16,000 Gallons(88 gpd) Sump pump? ❑ Yes ® No Last date of occupancy: September 2014 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is required for every Centerville MA 02632 9/11/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins 3113 Title 5 Oftidal inspection Fonn: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 ` 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is Centerville MA 02632 9/11/2014 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Approximately 30 years per Board of Health records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Tight Yes None Septic Tank(locate on site plan): 12„ Depth below gr& e: 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 gallon Sludge depth: 4" t5ins•3/13 Us 5 OfBdal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °Y 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner owner's Name information is required for every Centerville MA 02632 9/11/2014 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 26" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Measure 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 structural integrity of the septic tank appears sound. The inlet has a concrete cover 11"b.g. and the top of the tank is 1 V b.g. There is a sch.40 PVC pipe with PVC tee. The outlet has a concrete cover 12"b.g. and the top of the tank is 12"b.g. There is a sch.40 PVC pipe with PVC tee. The liquid level is at the outlet invert with no sign of backup or leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner owner's Name information is required for every Centerville MA 02632 9/11/2014 page. Cityrrown 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 ' 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owners Name information is Centerville MA 02632 9/11/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): OilDepth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box has a concrete cover 16" b.g. and the top of the box is 16" b.g. The D-box appears to be in fair condition with no sign of solids carryover. There is one inlet and one outlet. The liquid level is at the outlet invert with no sign of backup or leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is required for every Centerville MA 02632 9/11/2014 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: one 6'x 8'with stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leach pit appeared to be in good condition with a concrete cover 22" b.g. The top of the leach pit was 22"b.g. and the liquid level was 97" b.g., and the bottom of the leach pit was 115"b.g. The leach pit is at approximately 2%capacity. There is no sign of staining on the leach pit walls nor hydraulic failure in the area of the SAS. 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 t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is Centerville MA 02632 9/11/2014 required for every 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.): t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora le Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is Centerville MA 02632 9/11/2014 required for every i page. City/Town State Zip Code Date of Inspection spedion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately S I♦>_-rPL� [N G {4I LL Zo 4 7 �1 � al �ll A2 33 �t1 W (31 (33 3, 1511 E,c Is, ►�'G fle�K f34 )_J'�it -bwaLUNG naoSePitc OAK*_ �3 n D-r307-' (D L�Ac-N Inc. P6-ewLT N07- TO 5CAtZ- t5ins•3/13 Title 6 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 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is required for every Centerville MA 02632 9/11/2014 page. Citylrown 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: -25' below the bottom of the SAS 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: 2/22/84 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: According to the plan of record, test holes were completed on site to EL=86.8+/-b.g. and no groundwater was encountered. The bottom of the leach chamber is at EL=91.4+/-showing at least 4.6'of separation. According to the map of Groundwater Resources of Cape Cod, the elevation of the site is EL=70+/- and the elevation of groundwater is EL=35+/-and the bottom of the leach pit is EL=60+/-so there is a 25'separation to groundwater below the bottom of the SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Ofrrcial Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f - • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 100 Shoot Flying Hill Rd. Property Address Ray Cormier Owner Owner's Name information is Centerville MA 02632 9/11/2014 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A � 2 n � A � C ti a e" '�M Jev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner's Name: JOANNA JONSSON Owner's Address: BOX 721 CENTERVILLE, MA.02632 Date of Inspection: 6/11/01 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes ' _ Conditionally Passes _ Needs FurtY Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 6/11/01 The system inspector shall subm a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this insp tion. 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 DEI'. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM EFFICIENCY. RECOMMEND MOVING BUSHES AND.SPRINKLERS FROM AREA OF TANK AND D-BOX. RECOMMEND RAISING COVER OF LEACH PIT WHICH IS UNDER ROCK WALL ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This 'k' inspection does not address how the,system will perform in the future under the same or different conditions of use. Title 5 incnPrtinn rnrm 6/1 V?ffl l • ' r 1 r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE V RECOMMEND PUMPING EVERY TWO YEARS TO MAINTAIN SYSTEM EFFICIENCY. RECOMMEND MOVING BUSHES AND SPRINKLERS FROM AREA OF TANK AND D- BOX. RECOMMEND RAISING COVER OF LEACH PIT WHICH IS UNDER ROCK WALL B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND) in the for the following statements. if"not determined" please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank-and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if tHe,well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a .. i � ,Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 SHOOT'FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n1a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool.or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool;or privy is within a Zone I of a public well. X Any portion of a cesspool'or privy is within 50 feet of a private water supply well. X 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 Lasses if the well water analysis, performed at it DLP certified laboratory,.for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 31.0 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of:a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1 WPA)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 p above the large"systelt has fajieci The ow pr opertnr Af any jarge 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. ` a f Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property-Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes Nc X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period'? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site? X _ 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 ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems`? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220 Number of current residents:2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMM ERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203):n/agpd Basis of design flow(seats/personsJsgft,etc.): n/a Grease trap present(yes or no): NO , Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: Ig YEARS Were sewage odors detected when arriving at the site(yes or no): NO r _Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certifica(e) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet mid outlet tee or baffle condition, structm;al integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. RECOMMEND RAISING COVER OF LEACH PIT AND REMOVE BUSHES AND SPRINKLERS FROM AREA OF SEPTIC TANK GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm pr.-sent(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): DISTRIBUTION BOX IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): No Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Q Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY.DID NOT EXPOSE D-BOX WHICH WAS UNDER A STONE WALL. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a o I .Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE, MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system•including ties to at least two permanent reference landmarks or benchmarks. Locate all;yells within 100 feet. Locate where public water supply enters the building. n�k IA yo AAa �L Fl� N j. AP �� 3v in .Page 1 I of 1 1 OFFICIAL INSPECTIiON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 SHOOT FLYING HILL ROAD CENTERVILLE,MA 02632 Owner: JOANNA JONSSON Date of Inspection: 6/11/01 SITE EXAM _Slope _Surface water _Check cellar _Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain:jn/a You must describe how you established the high ground water elevation: US,GS MAPS AND CHARTS-10+FEET I II f No......(L ...[_.l..Y Fps.......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...._-......- ........................OF.-......-...........-.....-............-._------........ Appliratinn for Dhipoii al Workii Tonrnrtion r rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys em at: _ ;30 ` � Location Addr / / /7E� Lo o. (Qiw /�, - ,., a. .. -- -.---•--._....._�X-6----------------- -- r...% ..... Installer Address. T e of 3uilding Size Lot_. __2._:_'_:�' _.0 Sq. feet Dwelling—No. of Bedrooms.______Z_______________________________Expansion Attic ( ) Garbage Grinder (Ad) '4 Other—Type of Building p-, yp g ........ No. of persons...... ................ Showers ( ) — Cafeteria �o) Pa Other fixtyres --_------------_---_- - w Design Flow______._._ ~7.........................gallons per person per day. Total daily flow......J_..............................gallons. WSeptic Tank—Liquid capacity/ gallons Length a�_____ Width_ !P__. Diameter__?!y�!e_._ Depth____.:.�+ x Disposal Trench—No._.N,lp._.___ Width '1 ......... Total Length.N ,el4..._._ Total leaching area.�'_��9...... q. ft. Seepage Pit No......./.......... Diameter_._...1.41__.__. Depth below inlet...... Total leaching area......Z�4_sq. ft. Z Other Distribution box ( y) Dosing tank ) aPercolation Test Results Performed by...__ -_ _1%G ► ........Z._ _ IWYA____ Date________________________________________ a Test Pit No. l.L---I.....minutes per inch Depth of Test Pit_____ __. Degt�o ground water...�o�!_ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------- ................ 0 Description of Soil------.._0.":..�.__.....- ----•--......._ -•--••. V ..........................................�__.:../.. ... .. ,�i9i✓/� ---------------------------------------------4.%------ ---- -- --••--------•---------•-------•----------•-----••----•------------•----•----•-----•-• ................................. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ...----•------------------------------•--•••==••----•-•-------------•--•-•-•-••----......-•-••••---••••••-•••-•-----•---------•--•••--------•------•-----•-•-•----.._...---••--•-•••---------------- Agreement: The signed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisl i of ITI,,a. 5 t State Sanitary Code— The undersigned rtl:er agrees not to place the system in operation u a Certificat o om nce has been issuoeoby the board of h�11 _1111*1 n ........ �'��=!�',------ ----------- ...... D to Aplicati Approv B •••• ................................................................. .........---- 'te ppli ion Disapproved f e f ollowing reasons----------------------•-•-------•----•---•--------------•------------------------------------------------------- ----....--•---•----------------------•--....-•---••------------•-•---------------•-------•-•--------•-•--•------•-------------•--------------------•-••--••-------------•-----•---------•••------......_ Date PermitNo......................................................... Issued....................................................... Date �M lot THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................OF...........................----...........-- ApplirFation for Dispoti al Works Tomitraartion ranat Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_................................................................................ .......-•---•---------•-------........-----..._._... --- Location-Address or Lot No. ..............................................•-----------..........................••.......... .........._....................................................................................... Owner Address W Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )U Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .......................................... W Design Flcw............................................gallons per person per day. Total daily flow............................................gallons. Ix Septic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------------_- Diameter..........;.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Dist-ibution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date-----------......... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ( , Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P' •------------------------------••-•-•••--•---••-........ .•............... .................................................................................... 0 Description of Soil.................................................................................. -------------•--------------------------------------------••......-----.._.....-----• x W ••-••------•------....-•---•----------•-----•--••••-----------•----•••--••••--•-•••--•-...----•---•----••--••-••---------•-------••-•-•----•-•••-••••------•-••-•-•-----•--•••-•••••......-•----•------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ..--.... Agreement: The undesigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ! T/77R^ f the provis ory'of`ITiS 5.bf tine State Sanitary Code—The undersigned further agrees not to place the system in operation untia Certificate' ompliance has been issued by the board of health. , ri .....----•----•......................•--................................... D t e Applicati )n AppveB - '. -•..............•---------•--••-•---•-•-------.._..__.._....---- ate... ` ppli ion Disapproved f e following reasons:.................................................. ............................................................. ..•-••---------•-•----------•••••------------•--•------••••••.....••-••••.....-•---------•--•••--------------•-•••-•.....•---------•------------------••----••••-••-••-•--------•-•-•••---••-----------. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS > BOARD OF HEALTH • ..........................................OF.................................................................................... (IrdifirFab of T-ampliFaatrr Tng S TO CERTIFY, That the�Indwldual ,Sewage Disposal ys constructed ( r Repaired ( ) by.... •-•-•-.. ,_._>. ... •• .- ..................................•---.... ..-. _..------ �'' taller at.......... ........:...... .... .... .4—. ....... -------•----......------•-•------- --- ................... has een installed in accordance with the,,pro lions f TI�I 72 -r� 5 of e State Sanitary. od a d ed m the application for Disposal Works Construct' n Per rt No..._.. s `."'. 1 .----- dated-- :..:� ..__�..___-- THE ISSUANCE OF THIS C IFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................ ------------ . Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................................................................... No._ .. FEE. .................. .,,�.�--� Permission rs her granted. ,Z ..... .............. , ... t to Construct t/ Rep ( ) Disp" tem atNo..---.. ... .... ,.I ...........--r =-- ----' ---------------------------•-------......_...-•-----------••---...--•--........ Street as shown on the application for Disposal Works C stru i Permit o ................ Dated.......................................... ..................... Board of Health DATE-------------•-------.............----------................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS EITHER 7'NCSEPTIC TAN/C OR 20 FT.. M/N.:, LEACNt/YG Pt T ARE' MORE T'H AN /Z w®ELO AV j /D PT' M ,rR•�oE, A �O.O/AM.=7Ze CONCRETE: COYrAp SJNALL ®.E ®4Du61y7" TO GRAOE.�AN EX77MA CONCRETE i 4"PYC P/Plr /yEgYY CA ST /RO/Y CO//�R SN.4 L L L3E US�O • /F/N OR/✓,--1V,4 Y . • /� Raw FT.. - ? M/N. CONCRL�TE �..I A d GAVE CO✓ER CLEAN ..SA/V O BACXF/LL el 4«CAS �' - 'LAYER • - - N MON D/sT. � • A � , , .. . . . r • o , e • WASHED STZ?NE .BOX . . :. .rf 0 ,h ;_.' .. . : • SECT/VC • • - ► e • • • • • • 0 WASNEO STO*E 7 - ► O. • r• r • • • • • • o ,t p PREG4ST SEE�A6E lNfieR"�' ALE✓.4T/oNd �/T Gam- XCI, T/. 4Fs G�I IDLY. s r • • • • • • • • es a P/T DID E4U/V_ • 4 /NYERT AT Ot//4 D/NG IN E7,JZ72 r/C,. T.4/1/.K !o v,oFT � FT. G/AM. C�.SFF AMVA-A7 --V, 0U74.E7 SEPT/C 7*ANK /JVLE7�DISTRJB!?/ON B0,y �,. �Z FT GROUND J�IigTER T�L.E SECT/Q/V OF; OlITLETD/STR/BIJT/ON BQX9 9,d A7.. SEI�VVAGE O/•S/�AT�4 L .SYSTEM INLET LEACHING oIT. 9 7.5'FT TAJV"TIGN 4 LEACH//Yls �/T DESIG CRITERIA N D/N�c�+vs/ow 8 F't: Z _ D/ ENSIaN C NUM M BER OF O►EOu?GOt+IS-, : RGED/SPO.SALU/V/r iyg:o,� ; w... SOIL, .LOG TaTAL EST/A%WrED, FLO*V ZZ--0G.4L./OAY� SO/L TEST/OE/ SOIL 7ETS 2 SD/L TEST NUMBE�P AF LEACM/Nt► PITS ELEY. 9S & ELEY, PATE OF SOIL TEST SIDE 4&ACH/NG PER P/Jr PT. Log RESULTS IV/T/VESSED 8Y��a Q�,• � E�M'Q'� 907TOM LION/NG PER P/T SQ. . T. >�4 r+ �.3 f "/<!' PE/t COLAT/O!V AATAF#/ .'MI A�b NCK 1.TOTAL LEACH/NG A,4ZOA �"t' b SQ. FT �r 5v 3 �'= AENCOLi4T/GN RATE 2 MIN. /NCH RESFMVELE4CN!/V6AREA 1,4 b SQ. FT. S 'r\ S tl-l✓G% G.d.7 -57 tJ d TL y/i1/G 's[ AL •' o RSE v, r DKEC N'0.10951 O cr s T DREDGE ENCrIMACR/NG CQ,/NC. IF, 3ti �Fs�rONAL�� C--L G. 712 MAIN ST., 14YANN/9, AI ASS'. -. R s• DATE � ;' 1 : c"9•' NG G O UNP ;-V,4 r&M E/VCO(J/V T1rRE0 CL/ENT: Q GROUNQ. WATER:AT 4SLEN. No. 8 T OF •' JOB ' 3 o b 6 SH LOCATION S W A E PERMIT NO. Lot #2 Shoot Flying Hill Rd. ZY/W' VILLAGE Centerville INSTA LLER'S NAME i ADDRESS Robert B. Our Co. Inc. f Great Western Rd. North Harwich U I L D E R OR OWNER �risn Oacey DATE PERMIT ISSUED DATE COMPLIANCE ISSUED y/ 3o j S`' i n 41, .� a s cg ,. IL f p S jD 0 0 p SIG 1 s /off, �( C� Y j �aI/ s' se a,icK Y oaf LEGEND EXISTINO SPOT EL E.VATION 0„0 "�"" CERTIFIED PLOT PLAN ' EXISTING CONTOUR 0 ----- G FINISHED SPOT ELEVATION �4s. -T FINISHED CONTOUR 0 nnORSE tiff No.10951�O . . IN �4 APPROVED , BOARD OF HEALTH A9�FcisrE� `` / -�~ �FFSSIONA��a� `w,` / - 49 L C DATE AGENT SCALE, 40 f DATE� 2 , 2 - s DREDGE ENGINEERING Ca INC Anr �3 �4 CLIENT,hf r�'c ear atzuc� I CERTIFY THAT THE PROPOSEO , EGISTERE REGISTERED3 0 6 ' im JOB. NO .�._.+.,._�, �� ELDRED y BUILDING SHOWN ON THIS PLAN �C.IVIL LAND y �`� �, // ONFORMS TO THE ZONING LAWS ENGINEER OR.BYc �� ! . URV.EY ------- Isre� o� OF 13112n/srA9L.E MAS y ?1 q N 2= M I STREET CH"BYs .,1 � H,YANNIS; MAS$ iGy SNEET....z-OF Z- �, DATE REG. LAND SURVEYOR