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HomeMy WebLinkAbout0088 ACRE HILL ROAD - Health 88 Acre Hill Road A= 297 —058 Barnstable o Commonwealth of Massachusetts WP 0 7 06, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner owner's Name. information very Lion required for 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 e 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 A. General Information fillingng out forms on the computer, lj #' 10913 use only the tab 1. Inspector key to move your cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections a,y Company Name 19 Hummel Drive Company Address South Dennis MA 02660 Cityrrown State Zip Code (508)385- 1300 S1682 Telephone Number License Number ;,_ 010`_1 , B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority S May 20, 2015 Inspedors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 Official hwee m Forth:Subsurface Sewage Disposal System•Page 1 of 17 ' 1 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 rage. cityrrown state Zip code Date of inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 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 exfiltrabon 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•3J13 Title 5 0Mdal traDectim Form:SuDsraraoe Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 O(fidal Inspection Form:SubsuAboe Selvage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owners Name required in for eve 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 page. every Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of'a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ire•3/13 Me 5 OWWW Inspedw Form:Substsfew Sewage Dlsposel System•Pop 4 of 17 Commonwealth of Massachusetts W MEMO SM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owners Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20,2015 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•W13 Tide 5 Offidal trispedion Forth:$Lftwfece Sewage Disposal System-Page 5 of 17 ii Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is 88 Acre Hill Road, Barnstable MA 02630 May 20 2015 required for every Y , page. Cityrrown State Zip Code Date of inspection C. Checklist "yes" u a Check if the followinghave been done. You must indicate to yes or no as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3113 Title 5 Of al k apecdon Form:Subaidreee Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 City/Town page. State Zip Code Date of Inspedion D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 14=145,000 gals. 13=132,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date CommerciaUlndustrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 page. City/rown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: N/A Date Other(describe below): NIA General Information Pumping Records: Source of information: Last pumped in September 2014 per info from owner. 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 OtBcisi h Vsdon Form:SUM01�e Sewage 0"Osat System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner owners Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20,2015 page. Cityrrown State Zip Code Date of Inspedion D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Tank, d-box and leaching were installed on 6/27/78 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"+feet Material of construction: ❑cast iron ®40 PVC sch 20 pvc ®other(explain):. Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: 6"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: 5'X9'X6' 1000 gallon Sludge depth: 4" t5ins•3113 Title 5 Official Inspection Forth:SubsuAace 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 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 required for every Y 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 2'8" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet and pvc outlet tees were found present and in working order. No evidence of leakage or damage was found. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): 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/ADate t5ins-3113 Title 5 offidal hvVeWw Form:SLbuafm sewage Disposal system•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owners Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 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: N/A Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: N/A Capacity: N/A p ty' gallons Design Flow: N/A gallons per day Alarm present ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 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 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 page. c4fro" State Zip Code Date of InspeWon D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert level 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.): D-box was found level and in working order. 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.): N/A *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•3113 Title 5 Oftel trupectim Form:Subudace Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 6'X6' pit with 1 of stone ❑ 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.): Leach pit was found with 3'of water present with a visible stain line approx. 2'below inlet invert. No evidence of hydraulic failure or problems in the past were found at the time of inspection. 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 ❑ No t5ins-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 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 page. CityITown State Zip Code Date of Inspection D. System Information (cunt.) 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 t5ins-3113 Title 5 Offal 6upeefion Form:SLOadace Sewage Mposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately k- , A I ► , P l Asti I r_—' At � �l ' y t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner Owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20,2015 page. City/Town State Zip Code Data of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 14.0'+feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. 3/23/78 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: AIW 247 Zone C 22.4' 2.3'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 14.0'. Groundwater adjustment at the time of inspection was 2.3'. Bottom of leaching at 8.7'was found not to be located in the high groundwater elevation at the time of inspection. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. i t5ins•3/13 Title 5 Metal Mspedion Form:Subsurlaos Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 88 Acre Hill Road, Barnstable M-297 P-58 Property Address Robert Chaves Owner owner's Name information is required for every 88 Acre Hill Road, Barnstable MA 02630 May 20, 2015 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3M3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Pape 17 of 17 07 L0.CAT'ION SEWA PERMIT NO. VILLAGE ' INSTALLER'S NAME & ADDRESS BUILDER OR OWNER (9/9jr-d T r& v F DATE P-ERMIT ISSUED -7 � . 4 DAT E COMPLIANCE ISSUED ���,� I [ -� 0 �-�. �� ; v � � I � � r� � = l Z' .__����!r S t No........ - FIzs....P�:. .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ft /j `7 l .._..(...V-(et).. .....OF........ .-ARJA6..�i- r-Z_4-C..................................... Appliration for Disposal Works Tonstrnrtion Vernfit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: .....AUR-E.....M.4 ........... ..........1--o.-r........... ............................................................ Location-Address or Lot No. ......................................... ...... QIJST-R P.--•••-•--......------•-•-------------••-••---••---•.•- Owner Address a .U�.TORJ.")o �2°5........................................ -----. bAQu5T.9<34E ............ Installer Address dType of Building Size Lot..S.Z..1.710...Sq. feet Dwelling—No. of Bedrooms........ ..............................Expansion Attic (W) Garbage Grinder (00) Other—Type of Building ....!V.YA........... No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures .................................. --------------------------- -------------------••••••-----••--•••...........--•---------- W Design Flow........./1k..........................gallons per pe�sen per day. Total daily flow____.._....3.3o....................gallons. WSeptic Tank—Liquid capacity,lLtl�p.gallons Length,."o.`�. Width ..�lQ."� Diameter................ Depth. ` .��. x Disposal Trench—No..................... Width........_........... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......%_.__....... Diameter.._.__o_..... Depth below inlet.....16........... Total leaching area.;;2_A.0...sq. ft. Z Other Distribution box ( 14" Dosing tank ( ) , `"' Percolation Test Results Performed by..RQNAi_o._..19:..�x6fCi?a�.l.Z_�.. �.�e........ Date,AM..Rc-fL'.....�.������ aTest Pit No. 1....Z....minutes per inch Depth of Test Pit...14............ Depth to ground water________________________ f= Test Pit No. 2.�....`'__..minutes per, inch Depth of Test Pit._d_- ....-. Depth to ground water........................ p� ................-...........................................•••••••--•-•--•-•..............--.-•-•--......................................................... 0 Description of Soil-----..... ----JN ........s7vffsalG-------------9�9-_`-':7../6'9........152".6...--- U ---S.�9�tK � �.C1'91�.���. .SG�,� �:r.2/Li.�..�?!�w_'S---•------�'ou........Z0.7V �,e.5j ...l�sPCE.� W VNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si ned Date --------------------------------- ------------- I¢� Application Approved BY ...= -•� '-��'.7. :•••..•••... Date Application Disapproved for the following reasons--------------------------------•---------•-------------------•••----•---•-••••......••--•- •••--._.........•-- ....................................... ••---••---••••••-•-•...........••-•--•••-••-----......••-••-••..._...••••---••-•-•-------•--•--•----••-••-•----`-•-••••••••`•--•••......•-----......--..... ,d Date Permit No....................................................... .. Issued.----.. ---------- w Date NiFEic............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ................OF......... .................................... Appliration for Uhiposal Works Tonstrurtion ramit Application is hereby made for a Permit to'Construct ),,,or Repair an Individual Sewage Disposal System at: ,&CR_f_. ...&P.t... ........... Z .... ........ 1 "'5 T ......*i�07........­*---------------------------- dress Lot .......OE.1 iz........... ---------i------------------------------------- .........7IVr •............................................ ,Address ..................................I................... --------------------------------- ................................................................................................. Instal"I'er......... Address PQ 1� Type of Building Size Lot.. . .....12-0...Sq. feet U Dwelling—No. of Bedrooms:___:__` ...............................Expansion Attic Garbage Grinder (00) 'N 1A G1aOther—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures ................................... .................................................................................................. Design Flow______ VKO.............;------------gallons per'p" d Total daily flow......... ....................gallons. ... per ay. 04 Septic Tank—Liquid'caoacity/.qq9.gal1:ons. ' Length8...' Width d t 114.W.*flow ................ Depthl., p 7. Disposal Trench—No. .................... Width..................... Total Length...................... Total leaching area___-_ __-sq. ft. Seepage Pit-No...../---------- Diameter ... ....... Depth below inlet..... ............Total leaching area.gJ20...sq. f t. Z Other Distribution box Dosi tank . ' Percolation Test Results Performed by-W!R!,�......J>.... 6:;1 e�eO ..'R......S....o ........ Date. && &.....;U./?>49 Test Pit No. 14.._2".__._minutes per inch Depth of Test Pit...14.......... Depth to ground water....................... !;�.Test Pit No. 2. . :_...minutes per inch Depth of Test Pit-14!......... Depth to ground water........................ ...................;................................................................................;I......................... 0 Description of Soil.........0 - 49 4 0;VA .....................................I....?2 �......... ............... ........141IM-e....... -54 AO 5,1,0VIe A A soi4 C!g6?.A,$ r ---------------------------------------------------------------------------------- .... _.!eA6��F.........Z?.U......... ...... �4 -------------------------------------z........................................................................................................... .................................................�7... U Nature of Repairs or Alterations—Answer when applicable........................................�1....................................................... ..................w..................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITA YIZI 5 of the State Sanitary Code—The undersigned further agrees not to place i-hS ystem in operation until a Certificate of Compliance has been issued by,the board of health. �d ..... -------------- r rI' Applicationproved By........................................................ ....... ------ ........................................ Date Applicatidh Disapproved for the following reasons:.............................................................................................................. ................................. ..................................................................................................................................................................... Date PermitNo......................................................... IssuedL.................................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH ..........................................OF.......................­........ .....................(Irdifirate of Tompliatta RT iTiE .&!�That the Individual Sewage Disposal System constructed or Repaired z. by"�.. ..........qCEME....... . ....lut................ ..........*........------*----------------*----------- Insialler at................................................................................................Jon---........................................................---------------------------------- has been instilled in accordance with,the..,pyovisions of k(t The State Sanitary.,,jox*,as�scribed in the application for Disposal Works Construction Permit No......................................... dated---------- "---_-_--__-__--__________-• THE ISSUANCE OF THIS CERTIFICATE SHALL.NO.T1_`_,RE,CONSTRUED AS A GUARANTEE THAT THE SYSTE!Yt�WILL FUNCTION SATISFACTORY. DATE............................................................................... `Inspector......_..----------------------------..... .......................................... THE COMMONWEALTH OF MASSACHUSETTS ' BOAR&OF HEALTH,",, .....................................0 F....... ............................................................................... No......................... FEE........................ Peris hereby granted........................................................................................................................ .................... to Cons )-4r RopaQ(e ),MjvdividW'0ewage D!t�41��Iiil:��, at No. ...... ..................................................................................................................................................... ................ e VSt eet r 74P as shown on the application for Disposal Works Construction P Dated.......................................... r 4 A-----WAIW .... ............ .......................... - ------------------------------------------- Board of Xaith DATE----- _7 S_ ZLj....................................... FORM 1255 HOBBS & WARREN, 9NC., PUBLISHERS } LOT b 3 4 5. 8' Lo T LOT 7 � II' t 33 LEACH PIT l6 57170 TEST j HOLE- D15T '301% �x ESERVE O _ .___ /9 5 try T E 5 T t843 POLE O O 7 P P NRIL CLEV 354.79 +�.s9sw+..Mw+'F+w7^^.«.y+•✓....y++.y�.ru..�.+sa..r..a..+.rvs.+Mt.✓sc•rvr:w...suww.•.wr•:,-•wct..-4awcr-I+PIH(�:`NCMG; sJ,'.••K.KT'KWF'".'.'uaiRsr�.:-ate:....R:..:+.wr.y�. .......w,.a:� - .rtn -"-..-,{,.�,.ti.,raux....:..a..•r..sK:a:..K+�\, r-t...b / LOT 1 T 8 EST �J j } e NO WATER ENCOUNTERED ST �I 11 L. i:e MARCH L3 1978 TOWN WATER AVAILRQLE PAUL MURRAY - ELEV. /5.8 1 N S PECTO R �D - 48 LOAM AN.Q SUB 5 011- SCAL F i a8 ��- /6 8 FINE 5�1Nfa A4 AJ/Al U!t// l4 / r3 LJl D//vG S E770ACA.-f eEqu/.�E.ME.vT.s J� 30 F20iV T / S ` ? P RO P e E�2oo•�ls SE P T/G 5 yS TF M Con/S T2 UG TIO�I SHA L-L GOn/F02M TO MA SS • DES/G N FLOW _.1 GALI17A Y E N Vl,2 o/vM,C-/V TAL CODE: T/TL-e- A c/-/ 2,4 TE !!l'= ti �'; F .'- 7-7 /"33 A15�� L-P` NEALT,�! rzE�uGA T/On/S 70P OF 1p12oG'45 E D L _ c l �Q' Jc MA/VHOLE Co i/E,� Tp C-)c.7-En/D 70 �M'pE�✓/OClS GO t/Ek TO p2E✓EA.17- G-S !n./F/LT2A77.VG ,4 S D/ST. � � To.vE CovEz ,¢ BOX GA57-/ton/ — I'3"M/AI 4" D/A. ATE Z - �. - — -✓ 3 Mi,v P/7Z- V FLOW Lin/E M/N .'iTCH __� A.1 J " /rcf/ PST � y 2Y4,/FOOT /D"M/ / /4- ArooT D/A. _Y_ ��� MinJ ao0 WAS HED -� - /NvE�r /4.63 .4 CC�ST0AIE i //VVE.2T CA PA C/ TY ELEV A20UnlO SE,oT/G TA A/& / 8071-ai 4 OF. ` (WA TG2T/GhNT) /NVE,2T /� P�T'� � VEzr NO GA2G EAG G,2//JDE,- — I i I ' --- ------- 20' M/n//MUM S / TF, LAA.1 F'/?DPC/) S U SEV14 �- . LOCI 7-/O/U _ B WN-5Ty RLF NSA 55 ; 2EFE2�nlCE- -EEING I Qr 7 A 4Z C lulklA Lo SEDT/C TANK Z>/STTZ/BUT/ON 80X I N PLAN —R 0 K _3et__ P��� le �� _ Nu u �5OUTLETS A/VZ> L -ACA!/A/G F�/T F0,2 -7,p e� 2CED COn1CJzETE 3000 Ps! M/A/. Kt TEFL ,. 20000 � , •`� ``: "- /O LOADIAJ6 � 3 Ov"!1- L ,-:"iAi Z�,C-/VE VIVA ^,/OT TO BE LOCAT EJ Y-4P/V1 0 L,.J??4�-4°.:.� AP 7'-� IUJX 5 � s r��� /�/9'.x• O✓E e S yS TE A-,) Un/L E 5 5 N- ZO Y CERTIFY THAT TM,E FOUNDATION . S//00Al ON I?E-5JGA/ LOAD/A/G /S T HI5 PLAN i°.: L©CATED CAN 'T NE GROUN I) fi.5 - SPOON HEREON Ai40 IT WE'S CONIFOPM. TO Tflt BCJILDIN6- SE7,MCK REaWATtMENTS OX TOVE 70ta.)N OF DARN Sf°A4'4E � ., V,L {,',r - - ,